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Jaing TH, Wang YL, Chiu CC. Antiviral Agents for Preventing Cytomegalovirus Disease in Recipients of Hematopoietic Cell Transplantation. Viruses 2024; 16:1268. [PMID: 39205242 PMCID: PMC11359103 DOI: 10.3390/v16081268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/01/2024] [Accepted: 08/03/2024] [Indexed: 09/04/2024] Open
Abstract
This systematic review discusses the use of prophylaxis to prevent cytomegalovirus (CMV) infection in recipients who have undergone hematopoietic cell transplantation. It highlights the need for new approaches to control and prevent CMV infection. The approval of the anti-CMV drug letermovir has made antiviral prophylaxis more popular. CMV-specific T cell-mediated immunity tests are effective in identifying patients who have undergone immune reconstitution and predicting disease progression. Maribavir (MBV) has been approved for the treatment of post-transplant CMV infection/disease in adolescents. Adoptive T-cell therapy and the PepVax CMV vaccine show promise in tackling refractory and resistant CMV. However, the effectiveness of PepVax in reducing CMV viremia/disease was not demonstrated in a phase II trial. Cell-mediated immunity assays are valuable for personalized management plans, but more interventional studies are needed. MBV and adoptive T-cell therapy are promising treatments, and trials for CMV vaccines are ongoing.
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Affiliation(s)
- Tang-Her Jaing
- Division of Hematology and Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33315, Taiwan;
| | - Yi-Lun Wang
- Division of Hematology and Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33315, Taiwan;
| | - Chia-Chi Chiu
- Division of Nursing, Chang Gung Memorial Hospital, Taoyuan 33315, Taiwan;
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2
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Kielsen K, Møller DL, Pedersen AE, Nielsen CH, Ifversen M, Ryder LP, Müller K. Cytomegalovirus infection is associated with thymic dysfunction and chronic graft-versus-host disease after pediatric hematopoietic stem cell transplantation. Clin Immunol 2024; 265:110302. [PMID: 38942161 DOI: 10.1016/j.clim.2024.110302] [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: 05/09/2024] [Revised: 06/22/2024] [Accepted: 06/25/2024] [Indexed: 06/30/2024]
Abstract
Pediatric hematopoietic stem cell transplantation (HSCT) is challenged by chronic graft-versus-host disease (cGvHD) significantly affecting survival and long-term morbidity, but underlying mechanisms including the impact of post-HSCT CMV infection are sparsely studied. We first investigated the impact of CMV infection for development of cGvHD in 322 children undergoing standard myeloablative HSCT between 2000 and 2018. Clinically significant CMV infection (n = 61) was an independent risk factor for chronic GvHD in a multivariable Cox regression analysis (HR = 2.17, 95% CI = 1.18-3.97, P = 0.013). We next explored the underlying mechanisms in a subcohort of 39 children. CMV infection was followed by reduced concentration of recent thymic emigrants (17.5 vs. 51.9 × 106/L, P = 0.048) and naïve CD4+ and CD8+ T cells at 6 months post-HSCT (all P < 0.05). Furthermore, CD25highFOXP3+ Tregs tended to be lower in patients with CMV infection (2.9 vs. 9.6 × 106/L, P = 0.055), including Tregs expressing the naivety markers CD45RA and Helios. CD8+ T-cell numbers rose after CMV infection and was dominated by exhausted PD1-expressing cells (66% vs. 39%, P = 0.023). These findings indicate that post-HSCT CMV infection is a main risk factor for development of chronic GvHD after pediatric HSCT and suggest that this effect is caused by reduced thymic function with a persistently impaired production of naïve and regulatory T cells in combination with increased peripheral T-cell exhaustion.
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Affiliation(s)
- Katrine Kielsen
- Hematopoietic Stem Cell Transplantation and Primary Immune Deficiency, Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Departmen of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Dina Leth Møller
- Hematopoietic Stem Cell Transplantation and Primary Immune Deficiency, Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Claus Henrik Nielsen
- Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Department of Odontology, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Ifversen
- Hematopoietic Stem Cell Transplantation and Primary Immune Deficiency, Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lars Peter Ryder
- Departmen of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Klaus Müller
- Hematopoietic Stem Cell Transplantation and Primary Immune Deficiency, Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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3
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Hopff SM, Wingen-Heimann SM, Classen AY, Blau IW, Bug G, Hebermehl C, Kraus S, Penack O, Rettig AR, Schmitt T, Steinbrunn T, Teschner D, Vehreschild MJGT, Wehr C, Vehreschild JJ. Real-world experience with letermovir for cytomegalovirus-prophylaxis after allogeneic hematopoietic cell transplantation: A multi-centre observational study. J Infect 2024; 89:106220. [PMID: 38960103 DOI: 10.1016/j.jinf.2024.106220] [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: 04/05/2024] [Revised: 06/27/2024] [Accepted: 06/27/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVES Efficacy and safety of letermovir as prophylaxis for clinically significant cytomegalovirus infections (csCVMi) was evaluated in randomised controlled trials while most of the real-world studies are single-centre experiences. METHODS We performed a retrospective, multi-centre case-control study at six German university hospitals to evaluate clinical experiences in patients receiving CMV prophylaxis with letermovir (n = 200) compared to controls without CMV prophylaxis (n = 200) during a 48-week follow-up period after allogeneic hematopoietic cell transplantation (aHCT). RESULTS The incidence of csCMVi after aHCT was significantly reduced in the letermovir (34%, n = 68) compared to the control group (56%, n = 112; p < 0.001). Letermovir as CMV prophylaxis (OR 0.362) was found to be the only independent variable associated with the prevention of csCMVi. Patients receiving letermovir showed significantly better survival compared to the control group (HR = 1.735, 95% CI: 1.111-2.712; p = 0.014). Of all csCMVi, 46% (n = 31) occurred after discontinuation of letermovir prophylaxis. Severe neutropenia (<500 neutrophils/µL) on the day of the stem cell infusion was the only independent variable for an increased risk of csCMVi after the end of letermovir prophylaxis. CONCLUSIONS Our study highlights the preventive effects of letermovir on csCMVi after aHCT. A substantial proportion of patients developed a csCMVi after discontinuation of letermovir. In particular, patients with severe neutropenia require specific attention after drug discontinuation.
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Affiliation(s)
- Sina M Hopff
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Centre for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany.
| | - Sebastian M Wingen-Heimann
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Germany; University of Applied Sciences for Economics and Management (FOM), Cologne, Germany
| | - Annika Y Classen
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Centre for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Germany; University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Igor-Wolfgang Blau
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Gesine Bug
- Goethe University Frankfurt, University Hospital, Department of Medicine 2, Frankfurt am Main, Germany
| | - Corinna Hebermehl
- University Medical Centre of the Johannes Gutenberg University Mainz, Department of Hematology and Medical Oncology, Mainz, Germany
| | - Sabrina Kraus
- University Hospital of Würzburg, Department of Internal Medicine II, Würzburg, Germany
| | - Olaf Penack
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Hematology, Oncology and Tumorimmunology, Augustenburger Platz 1, 13353 Berlin, Germany; Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Andrés R Rettig
- Department of Medicine I/ Hematology, Oncology and Stem Cell Transplantation, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Timo Schmitt
- University Medical Centre of the Johannes Gutenberg University Mainz, Department of Hematology and Medical Oncology, Mainz, Germany
| | - Torsten Steinbrunn
- University Hospital of Würzburg, Department of Internal Medicine II, Würzburg, Germany; Dana-Farber Cancer Institute, Department of Medical Oncology, Harvard Medical School, Boston, MA, USA
| | - Daniel Teschner
- University Medical Centre of the Johannes Gutenberg University Mainz, Department of Hematology and Medical Oncology, Mainz, Germany; University Hospital of Würzburg, Department of Internal Medicine II, Würzburg, Germany
| | - Maria J G T Vehreschild
- Goethe University Frankfurt, University Hospital Frankfurt, Department of Internal Medicine, Infectious Diseases, Frankfurt am Main, Germany
| | - Claudia Wehr
- Department of Medicine I/ Hematology, Oncology and Stem Cell Transplantation, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - J Janne Vehreschild
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Germany; German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany; Goethe University Frankfurt, University Hospital, Department of Medicine 2, Frankfurt am Main, Germany
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4
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Baber A, Calvet L, Vissac C, Salmona M, Legoff J, De Jong A, Mariotte E, Zafrani L, Azoulay E, Darmon M. Cytomegalovirus infection in intensive care unit patients with hematological malignancies: Characteristics and clinical outcomes. J Crit Care 2024; 82:154766. [PMID: 38479298 DOI: 10.1016/j.jcrc.2024.154766] [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: 01/08/2024] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is associated with poor outcome in ICU patients. However, data on immunocompromised patients are scarce. This study aims to describe characteristics and outcomes of critically ill hematological patients and CMV infection. CMV disease characteristics and relationship between CMV viral load, CMV disease, coinfections by other pathogens and outcomes are described. METHODS Retrospective single center study (Jan 2010-Dec 2017). Adult patients, admitted to the ICU, having underlying hematological malignancy and CMV infection were included. Results are reported as median (interquartile) or n (%). Factors associated with hospital mortality or CMV disease were analysed using logistic regression. RESULTS 178 patients were included (median age 55y [42-64], 69.1% male). Hospital mortality was 53% (n = 95). Median viral load was 2.7 Log [2.3-3.5]. CMV disease occurred in 44 (24.7%) patients. Coinfections concerned 159 patients (89.3%). After adjustment for confounders, need for vasopressors (OR 2.53; 95%CI 1.11-5.97) and viral load (OR 1.88 per Log; 95%CI 1.29-2.85) were associated with hospital mortality. However, neither CMV disease nor treatment were associated with outcomes. Allogeneic stem cell transplantation (OR 2.55; 95%CI 1.05-6.16), mechanical ventilation (OR 4.11; OR 1.77-10.54) and viral load (OR 1.77 per Log; 95%CI 1.23-2.61) were independently associated with CMV disease. Coinfections were not associated with CMV disease or hospital mortality. CONCLUSION In critically-ill hematological patients, CMV viral load is independently associated with hospital mortality. Conversely, neither CMV disease nor treatment was associated with outcome suggesting viral load to be a surrogate for immune status rather than a cause of poor outcome.
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Affiliation(s)
- A Baber
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - L Calvet
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - C Vissac
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - M Salmona
- Université de Paris; Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Department of microbiology, Paris, France
| | - J Legoff
- Université de Paris; Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Department of microbiology, Paris, France
| | - A De Jong
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - E Mariotte
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - L Zafrani
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - E Azoulay
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France
| | - M Darmon
- Université de Paris, Assistance Publique-Hôpitaux de Paris; Hôpitaux universitaires Saint-Louis, Lariboisière, Fernand-Widal; Intensive care unit, Paris, France.
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5
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Silva F, Martins A, Ferraz P, Lopes D, Bastos J, Joana Araújo JA, Trigo F, Pinto R, Silva-Pinto A. [Management of Cytomegalovirus Infection in Allogeneic Hematopoietic Stem Cell Transplant Recipients]. ACTA MEDICA PORT 2024. [PMID: 39008637 DOI: 10.20344/amp.21441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/04/2024] [Indexed: 07/17/2024]
Abstract
Cytomegalovirus (CMV) is a type of double-stranded deoxyribonucleic acid virus belonging to the herpesviridae family. Following a primary infection, the virus becomes latent in various types of white blood cells. Cytomegalovirus infection can remain latent or become active, especially in immunocompromised individuals, such as those undergoing hematopoietic stem cell transplantation (HSCT), where CMV reactivation can occur. In this context, CMV infection is common and associated with high rates of morbidity and mortality. Pneumonia is one of the most serious complications, with mortality rates exceeding 50%. Additionally, even in the absence of organ-specific disease, CMV infection is related to increased mortality unrelated to hematologic neoplasm recurrence. Given the frequency and severity of this infection in HSCT patients, it is crucial to implement effective strategies for monitoring, prevention, and treatment. This guideline was developed to identify patient groups that benefit from a systematic approach to CMV infection and to define the most appropriate strategy for each group. Monitoring CMV viral load in peripheral blood is crucial, especially in patients at moderate to high risk of active infection. Primary prophylaxis with letermovir (an antiviral drug) is recommended to reduce the incidence of active infection, especially in high-risk patients. Secondary prophylaxis with valganciclovir (antiviral drug) is recommended after an episode of active infection, while preemptive and disease treatment is based on monitoring viral load and clinical response. The aim of this guideline is to improve the approach to CMV infection in HSCT patients, ensuring an effective and safe preventive and therapeutic approach.
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Affiliation(s)
- Fernando Silva
- Serviço de Doenças Infeciosas. Unidade Local de Saúde São João. Porto. Portugal
| | - António Martins
- Serviço de Doenças Infeciosas. Unidade Local de Saúde São João. Porto. Portugal
| | - Paula Ferraz
- Serviço de Farmacologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - Diogo Lopes
- Serviço de Farmacologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - Juliana Bastos
- Serviço de Hematologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | | | - Fernanda Trigo
- Serviço de Hematologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - Ricardo Pinto
- Serviço de Hematologia Clínica. Unidade Local de Saúde São João. Porto. Portugal
| | - André Silva-Pinto
- Serviço de Doenças Infeciosas. Unidade Local de Saúde São João. Porto; Departamento de Medicina. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
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6
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Khan F, Müller TR, Kasmapour B, Ynga-Durand MA, Eiz-Vesper B, von Einem J, Busch DH, Cicin-Sain L. Dynamic monitoring of viral gene expression reveals rapid antiviral effects of CD8 T cells recognizing the HCMV-pp65 antigen. Front Immunol 2024; 15:1439184. [PMID: 39104541 PMCID: PMC11299495 DOI: 10.3389/fimmu.2024.1439184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 06/24/2024] [Indexed: 08/07/2024] Open
Abstract
Introduction Human Cytomegalovirus (HCMV) is a betaherpesvirus that causes severe disease in immunocompromised transplant recipients. Immunotherapy with CD8 T cells specific for HCMV antigens presented on HLA class-I molecules is explored as strategy for long-term relief to such patients, but the antiviral effectiveness of T cell preparations cannot be efficiently predicted by available methods. Methods We developed an Assay for Rapid Measurement of Antiviral T-cell Activity (ARMATA) by real-time automated fluorescent microscopy and used it to study the ability of CD8 T cells to neutralize HCMV and control its spread. As a proof of principle, we used TCR-transgenic T cells specific for the immunodominant HLA-A02-restricted tegumental phosphoprotein pp65. pp65 expression follows an early/late kinetic, but it is not clear at which stage of the virus cycle it acts as an antigen. We measured control of HCMV infection by T cells as early as 6 hours post infection (hpi). Results The timing of the antigen recognition indicated that it occurred before the late phase of the virus cycle, but also that virion-associated pp65 was not recognized during virus entry into cells. Monitoring of pp65 gene expression dynamics by reporter fluorescent genes revealed that pp65 was detectable as early as 6 hpi, and that a second and much larger bout of expression occurs in the late phase of the virus cycle by 48 hpi. Since transgenic (Tg)-pp65 specific CD8 T cells were activated even when DNA replication was blocked, our data argue that pp65 acts as an early virus gene for immunological purposes. Discussion ARMATA does not only allow same day identification of antiviral T-cell activity, but also provides a method to define the timing of antigen recognition in the context of HCMV infection.
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Affiliation(s)
- Fawad Khan
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
- German Center for Infection Research (DZIF), Partner site Hannover/Braunschweig, Braunschweig, Germany
- Centre for Individualized Infection Medicine (CIIM), a Joint Venture of Helmholtz Centre for Infection Research and Hannover Medical School, Hannover, Germany
| | - Thomas R. Müller
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich (TUM), Munich, Germany
- German Center for Infection Research (DZIF), Partner site Munich, Munich, Germany
| | - Bahram Kasmapour
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Centre for Individualized Infection Medicine (CIIM), a Joint Venture of Helmholtz Centre for Infection Research and Hannover Medical School, Hannover, Germany
| | - Mario Alberto Ynga-Durand
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Centre for Individualized Infection Medicine (CIIM), a Joint Venture of Helmholtz Centre for Infection Research and Hannover Medical School, Hannover, Germany
| | - Britta Eiz-Vesper
- Institute for Transfusion Medicine, Hannover Medical School, Hannover, Germany
| | - Jens von Einem
- Institute of Virology, University Hospital Ulm, Ulm, Germany
| | - Dirk H. Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich (TUM), Munich, Germany
- German Center for Infection Research (DZIF), Partner site Munich, Munich, Germany
| | - Luka Cicin-Sain
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
- German Center for Infection Research (DZIF), Partner site Hannover/Braunschweig, Braunschweig, Germany
- Centre for Individualized Infection Medicine (CIIM), a Joint Venture of Helmholtz Centre for Infection Research and Hannover Medical School, Hannover, Germany
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7
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AlQahtani HY, AlSuhebany N, Alowais SA, AlShehri B, Althemery A, Alghanim A, Alqahtani H, Alkhathran L, Alyaqub M, Alsulimani M, AlHarbi A, Alhatmi H, Almansour S, Almohaya A, Bosaeed M. Characterization of recurrent cytomegalovirus reactivations post allogenic stem cell transplantation in a population with high seropositivity. Virol J 2024; 21:149. [PMID: 38956615 PMCID: PMC11218190 DOI: 10.1186/s12985-024-02421-y] [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: 06/16/2024] [Accepted: 06/21/2024] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVES This study aimed to characterize incidences of CMV reactivations within one year post-allo-SCT and identify risk factors for CMV second reactivation episode in population with high seropositivity where first CMV reactivation episode deemed to be high. METHODS This retrospective cohort study analyzed data from 359 allo-SCT patients aged 14 and older admitted to a tertiary academic hospital. Data on demographic and clinical factors, CMV serostatus, conditioning regimens, graft-versus-host disease prophylaxis, engraftment time, and CMV reactivations were collected. RESULTS First and second CMV reactivations occurred in 88.9% and 18.4% of post-allo-SCT patients respectively. Patients were stratified into two groups based on primary disease necessitating allo-SCT, patients with malignant (Group 1) and non-malignant (Group 2) hematological disease. Factors associated with the second reactivation included cord blood as a stem cell source, human leukocyte antigen mismatch, acute graft-versus-host disease, and hematological malignancies. Patients with non-malignant hematological disease displayed better outcomes, including a higher rate of spontaneous clearance of first CMV reactivation (70% versus 49.4%) and lower rates of second CMV reactivation (9.6% versus 31%) than those with malignant hematological disease. The one-year overall survival rate was 87.7% (95.5% in non-malignant hematological disease and 78.13% in malignant hematological disease). CONCLUSION Our findings are concordant with previous local study in regard to high rate of first CMV reactivation post-allo-SCT. It appears that patients with nonmalignant hematological disease had better outcomes, such as lower second CMV reactivation and higher survival rates compared to patients with malignant hematological disease. Further investigation is needed to identify other factors affecting recurrent CMV reactivations in allo-SCT in patients with malignant hematological disease.
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Affiliation(s)
- Hajar Y AlQahtani
- Department of Pharmaceutical Care, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Nada AlSuhebany
- Department of Pharmaceutical Care, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shuroug A Alowais
- Department of Pharmaceutical Care, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Bashayer AlShehri
- Department of Pharmaceutical Care, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdullah Althemery
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Al Riyadh Province, Saudi Arabia
| | - Amirah Alghanim
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hessa Alqahtani
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Lama Alkhathran
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majd Alyaqub
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mariam Alsulimani
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmad AlHarbi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hind Alhatmi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sarah Almansour
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Abdulellah Almohaya
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Bosaeed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Division of Infectious Diseases, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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8
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Fukuda M, Hattori J, Ohkubo R, Watanabe A, Maekawa S. Real-World Safety and Effectiveness of Letermovir in Patients Undergoing Allogenic Hematopoietic Stem Cell Transplantation: Final Results of Post-Marketing Surveillance in Japan. Clin Drug Investig 2024; 44:527-540. [PMID: 38935253 PMCID: PMC11263243 DOI: 10.1007/s40261-024-01376-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND OBJECTIVE Cytomegalovirus (CMV) is a common opportunistic infection after allogenic hematopoietic stem cell transplantation (allo-HSCT). Letermovir, an inhibitor of CMV DNA terminase, is approved for CMV prophylaxis in allo-HSCT patients. We report the final results of post-marketing surveillance of letermovir in Japan. METHODS The case report forms were drafted in part by the Japanese Data Center for Hematopoietic Cell Transplantation using data elements in the Transplant Registry Unified Management Program and sent to individual HSCT centers to decrease the burden of reporting. Hematopoietic stem cell transplantation patients who received letermovir between May 2018 and May 2022 were registered. Data collected included physician-assessed adverse events/adverse drug reactions and clinical effectiveness (development of CMV disease, CMV antigen status, and use of preemptive therapy). RESULTS A total of 821 HSCT patients were included in the safety analyses. Adverse drug reactions occurred in 11.33% of patients, with serious adverse drug reactions in 3.05%. The five most common adverse drug reactions were nausea (1.58%), renal impairment (1.46%), and acute graft versus host disease, CMV test positive, and hepatic function abnormal (0.61% each). A total of 670 patients were eligible for effectiveness analyses. Among these patients, 16.57% and 28.66% required preemptive therapy through week 14 and week 48, respectively. In addition, relatively few patients developed CMV disease throughout the follow-up period (1.34% at week 14 and 3.85% at week 48). CONCLUSIONS This final analysis of post-marketing surveillance with up to 48 weeks follow-up period in Japan provides further evidence supporting the safety profile and effectiveness of letermovir for CMV prophylaxis in patients undergoing allo-HSCT in real-world settings.
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Affiliation(s)
- Masaki Fukuda
- Medical Affairs, MSD K.K., Kitanomaru Square, 1-13-12, Kudan-kita, Chiyoda-ku, Tokyo, 102-8667, Japan.
| | - Junko Hattori
- Medical Affairs, MSD K.K., Kitanomaru Square, 1-13-12, Kudan-kita, Chiyoda-ku, Tokyo, 102-8667, Japan
| | - Rika Ohkubo
- Medical Affairs, MSD K.K., Kitanomaru Square, 1-13-12, Kudan-kita, Chiyoda-ku, Tokyo, 102-8667, Japan
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9
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Sassine J, Siegrist EA, Shafat TF, Chemaly RF. Advances and prospect in herpesviruses infections after haematopoietic cell transplantation: closer to the finish line? Clin Microbiol Infect 2024:S1198-743X(24)00300-8. [PMID: 38945270 DOI: 10.1016/j.cmi.2024.06.020] [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: 04/20/2024] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Herpesviruses represent common and significant infectious complications after allogeneic haematopoietic cell transplantation (HCT). In the last decade, major advances in the prevention and treatment of these infections were accomplished. OBJECTIVES The aim of this paper is to review the recent advances in the prophylaxis and treatment of herpesvirus infections after allogeneic HCT, to assess the persisting challenges, and to offer future directions for the prevention and management of these infections. SOURCES We searched PubMed for relevant literature regarding specific herpesviruses complicating allogeneic HCT through March 2024. CONTENT The largest advances in this past decade were witnessed for cytomegalovirus (CMV) with the advent of letermovir for primary prophylaxis and the development of maribavir as an option for refractory and/or resistant CMV infections in transplant recipients. For varicella zoster virus, prevention of reactivation with the recombinant zoster vaccine offers an additional prophylactic intervention. Pritelivir is being explored for the treatment of drug-resistant or refractory Herpes simplex virus infections. Although rituximab is now an established option for preemptive therapy for Epstein-Barr virus, Human Herpesvirus-6 remains the most elusive virus of the herpesvirus family, with a lack of evidence supporting the benefit of any agent for prophylaxis or for optimal preemptive therapy. IMPLICATIONS Although considerable advances have been achieved for the treatment and prevention of herpes virus infections, most notably with CMV, the coming years should hold additional opportunities to tame the beast in these herpesviruses postallogeneic HCT, with the advent of new antivirals, cell-mediated immunity testing, and cytotoxic T lymphocytes infusions.
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Affiliation(s)
- Joseph Sassine
- Infectious Diseases Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | | | - Tali Fainguelernt Shafat
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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10
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Uhlemann H, Epp K, Klesse C, Link-Rachner CS, Surendranath V, Günther UP, Schetelig J, Heidenreich F. Shape of the art: TCR-repertoire after allogeneic hematopoietic cell transplantation. Best Pract Res Clin Haematol 2024; 37:101558. [PMID: 39098804 DOI: 10.1016/j.beha.2024.101558] [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: 12/30/2023] [Revised: 05/03/2024] [Accepted: 06/27/2024] [Indexed: 08/06/2024]
Abstract
The human adaptive immune repertoire is characterized by specificity and diversity to provide immunity against past and future tasks. Such tasks are mainly infections but also malignant transformations of cells. With its multiple lines of defense, the human immune system contains both, rapid reaction forces and the potential to capture, disassemble and analyze strange structures in order to teach the adaptive immune system and mount a specific immune response. Prevention and mitigation of autoimmunity is of equal importance. In the context of allogeneic hematopoietic cell transplantation (HCT) specific challenges exist with the transfer of cells from the adapted donor immune system to the immunosuppressed recipient. Those challenges are immunogenetic disparity between donor and host, reconstitution of immunity early after HCT by expansion of mature immune effector cells, and impaired thymic function, if the recipient is an adult (as it is the case in most HCTs). The possibility to characterize the adaptive immune repertoire by massively parallel sequencing of T-cell receptor gene rearrangements allows for a much more detailed characterization of the T-cell repertoire. In addition, high-dimensional characterization of immune effector cells based on their immunophenotype and single cell RNA sequencing allow for much deeper insights in adaptive immune responses. We here review, existing - still incomplete - information on immune reconstitution after allogeneic HCT. Building on the technological advances much deeper insights into immune recovery after HCT and adaptive immune responses and can be expected in the coming years.
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Affiliation(s)
- Heike Uhlemann
- University Hospital Carl Gustav Carus, Dresden, Germany; DKMS Group gGmbH, Clinical Trials Unit, Dresden, Germany.
| | - Katharina Epp
- University Hospital Carl Gustav Carus, Dresden, Germany
| | | | | | | | | | - Johannes Schetelig
- University Hospital Carl Gustav Carus, Dresden, Germany; DKMS Group gGmbH, Clinical Trials Unit, Dresden, Germany
| | - Falk Heidenreich
- University Hospital Carl Gustav Carus, Dresden, Germany; DKMS Group gGmbH, Clinical Trials Unit, Dresden, Germany
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11
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Nakamura R, La Rosa C, Yang D, Hill JA, Rashidi A, Choe H, Zhou Q, Lingaraju CR, Kaltcheva T, Longmate J, Drake J, Slape C, Duarte L, Al Malki MM, Pullarkat VA, Aribi A, Devine S, Verneris MR, Miller JS, Forman SJ, Aldoss I, Diamond DJ. A phase II randomized, placebo-controlled, multicenter trial to evaluate the efficacy of cytomegalovirus PepVax vaccine in preventing cytomegalovirus reactivation and disease after allogeneic hematopoietic stem cell transplant. Haematologica 2024; 109:1994-1999. [PMID: 38328852 PMCID: PMC11141674 DOI: 10.3324/haematol.2023.284544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024] Open
Abstract
Not available.
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Affiliation(s)
| | - Corinna La Rosa
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Dongyun Yang
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA
| | | | - Armin Rashidi
- Fred Hutchinson Cancer Center, Seattle, WA, USA; Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | - Hannah Choe
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Qiao Zhou
- Department of Hematology and Hematopoietic Cell Transplantation
| | | | | | - Jeffrey Longmate
- Department of Computational and Quantitative Medicine, City of Hope National Medical Center, Duarte, CA
| | | | - Cynthia Slape
- Department of Clinical Research, City of Hope National Medical Center, Duarte, CA
| | - Lupe Duarte
- Department of Hematology and Hematopoietic Cell Transplantation
| | | | | | - Ahmed Aribi
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Steven Devine
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Michael R Verneris
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, CO
| | - Jeffrey S Miller
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN
| | | | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation
| | - Don J Diamond
- Department of Hematology and Hematopoietic Cell Transplantation.
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12
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Walling M, Seago K, Dillaman M, Yingling S, Wen S, Veltri L, Ross KG, Cumpston A. Analysis of spontaneous cytomegalovirus clearance after low level reactivation using a pre-emptive treatment threshold of 4,000 IU/mL in allogeneic hematopoietic cell transplant recipients. J Infect Chemother 2024:S1341-321X(24)00142-9. [PMID: 38815653 DOI: 10.1016/j.jiac.2024.05.010] [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: 01/29/2024] [Revised: 05/17/2024] [Accepted: 05/27/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) can be a serious complication after allogeneic hematopoietic cell transplant (HCT). CMV viral load is routinely monitored, and pre-emptive therapy is initiated to prevent CMV viremia from developing into CMV organ disease based on institutional thresholds. There is no established universal threshold for pre-emptive therapy and many centers utilize different strategies. METHODS Allogeneic HCT recipients at WVU Medicine from 2009 to 2021 were routinely initiated on pre-emptive CMV treatment for a PCR viral threshold above 4000 IU/mL. Adult patients with quantifiable values below this threshold, were analyzed to evaluate the rate of spontaneous clearance without initiation of CMV-directed therapy, during their first episode of CMV reactivation. This study excluded any patients that received letermovir prophylaxis. RESULTS Sixty patients were included in the analysis. The spontaneous clearance rate was 60 %. The risk factors that were associated with a lower spontaneous clearance rate were reactivation within thirty days after transplant (p = 0.031), presence of graft-versus-host-disease (p = 0.031), and CMV PCR values of 2500-4000 IU/mL (p = 0.02). Although these patients had lower rates of spontaneous clearance, they still spontaneously cleared in 42 %, 42 %, and 43 % of the cases, respectively. CONCLUSION Delaying pre-emptive treatment until a CMV PCR value of 4000 IU/mL is reached appears appropriate and decreases unnecessary treatment toxicity and resistance.
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Affiliation(s)
- Madison Walling
- Department of Pharmacy, West Virginia University Hospital, WV, USA.
| | - Kelsea Seago
- Department of Pharmacy, West Virginia University Hospital, WV, USA; Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, WV, USA
| | - Megan Dillaman
- Department of Pharmacy, West Virginia University Hospital, WV, USA; Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, WV, USA
| | - Spencer Yingling
- Department of Pharmacy, West Virginia University Hospital, WV, USA; Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, WV, USA
| | - Sijin Wen
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Lauren Veltri
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, WV, USA
| | - Kelly G Ross
- Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, WV, USA
| | - Aaron Cumpston
- Department of Pharmacy, West Virginia University Hospital, WV, USA; Osborn Hematopoietic Malignancy and Transplantation Program, West Virginia University, WV, USA
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13
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Lakkaraja M, Mauguen A, Boulad F, Cancio MI, Curran KJ, Harris AC, Kernan NA, Klein E, Kung AL, Oved J, Prockop S, Scaradavou A, Spitzer B, O'Reilly RJ, Boelens JJ. Impact of rabbit anti-thymocyte globulin (ATG) exposure on outcomes after ex vivo T-cell-depleted hematopoietic cell transplantation in pediatric and young adult patients. Cytotherapy 2024; 26:351-359. [PMID: 38349310 PMCID: PMC10997457 DOI: 10.1016/j.jcyt.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 11/03/2023] [Accepted: 01/24/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND AIMS Traditional weight-based dosing of rabbit anti-thymocyte globulin (rATG) used in allogeneic hematopoietic cell transplantation (HCT) to prevent graft-versus-host disease (GVHD) and graft rejection leads to variable exposures. High exposures induce delayed CD4+immune reconstitution (CD4+IR) and greater mortality. We sought to determine the impact of rATG exposure in children and young adults receiving various types of EX-VIVO T-cell-depleted (EX-VIVO-TCD) HCT. METHODS Patients receiving their first EX-VIVO-TCD HCT (CliniMACS CD34+, Isolex or soybean lectin agglutination), with removal of residual T cells by E-rosette depletion (E-) between 2008 and 2018 at Memorial Sloan Kettering Cancer Center were retrospectively analyzed. rATG exposure post-HCT was estimated (AU*d/L) using a validated population pharmacokinetic model. Previously defined rATG-exposures, <30, 30-55, ≥55 AU*d/L, were related with outcomes of interest. Cox proportional hazard and cause-specific models were used for analyses. RESULTS In total, 180 patients (median age 11 years; range 0.1-44 years) were included, malignant 124 (69%) and nonmalignant 56 (31%). Median post-HCT rATG exposure was 32 (0-104) AU*d/L. Exposure <30 AU*d/L was associated with a 3-fold greater probability of CD4+IR (P < 0.001); 2- to 4-fold lower risk of death (P = 0.002); and 3- to 4-fold lower risk of non-relapse mortality (NRM) (P = 0.02). Cumulative incidence of NRM was 8-fold lower in patients who attained CD4+IR compared with those who did not (P < 0.0001). There was no relation between rATG exposure and aGVHD (P = 0.33) or relapse (P = 0.23). Effect of rATG exposure on outcomes was similar in three EX-VIVO-TCD methods. CONCLUSIONS Individualizing rATG dosing to target a low rATG exposure post-HCT while maintaining total cumulative exposure may better predict CD4+IR, reduce NRM and increase overall survival, independent of the EX-VIVO-TCD method.
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Affiliation(s)
- Madhavi Lakkaraja
- Fred Hutchinson Cancer Center, Seattle, Washington, USA; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Farid Boulad
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Maria I Cancio
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Kevin J Curran
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Andrew C Harris
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Nancy A Kernan
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Elizabeth Klein
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Andrew L Kung
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Joseph Oved
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Susan Prockop
- Dana Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Andromachi Scaradavou
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Barbara Spitzer
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Richard J O'Reilly
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
| | - Jaap Jan Boelens
- Department of Pediatrics, BMT Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA.
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14
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Qiu Y, Zhang Y, Teng M, Cheng S, Du Q, Yang L, Wang Q, Wang T, Wang Y, Dong Y, Dong H. Efficacy, Safety, and Cost-effectiveness Analysis of Antiviral Agents for Cytomegalovirus Prophylaxis in Allogeneic Hematopoietic Stem Cell Transplantation Recipients. Transplantation 2024; 108:1021-1032. [PMID: 38049935 DOI: 10.1097/tp.0000000000004856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) infection is associated with higher non-relapse mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). But the preferred drug for preventing cytomegalovirus infection is still controversial. We evaluate the efficacy, safety, and cost-effectiveness of antiviral agents based on the most recent studies. METHODS A pairwise and network meta-analysis was conducted to obtain direct and indirect evidence of antivirals. The cost of allo-HSCT recipients in a teaching hospital was collected, and a cost-effectiveness analysis using a decision tree combined with Markov model was completed from the perspective of allo-HSCT recipients over a lifetime horizon. RESULTS A total of 19 RCTs involving 3565 patients (8 antivirals) were included. In the network meta-analysis, relative to placebo, letermovir, valacyclovir, and ganciclovir significantly reduced CMV infection incidence; ganciclovir significantly reduced CMV disease incidence; ganciclovir significantly increased the incidence of serious adverse event; none of antivirals significantly reduced all-cause mortality. Based on meta-analysis and Chinese medical data, the incremental cost-effectiveness ratios (ICER) per quality-adjusted life year (QALY) saved for maribavir, acyclovir, valacyclovir, ganciclovir, and letermovir relative to placebo corresponded to US$216 635.70, US$11 590.20, US$11 816.40, US$13 049.90, and US$12 189.40, respectively. One-way sensitivity analysis showed the most influential parameter was discount rate. The probabilistic sensitivity analysis indicated a 53.0% probability of letermovir producing an ICER below the willingness-to-pay threshold of US$38 824.23/QALY. The scenario analysis demonstrated prophylaxis with letermovir is considered cost-effective in the United States. CONCLUSIONS Currently, letermovir is an effective and well-tolerated treatment for preventing CMV infection, and it might be a cost-effective choice in allo-HSCT recipients in China.
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Affiliation(s)
- Yulan Qiu
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yijing Zhang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mengmeng Teng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shiqi Cheng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qian Du
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Luting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Quanfang Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yan Wang
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Haiyan Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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15
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Cui J, Zhou Y, Zhao K, Li X, Zhang H, Zhang X, Sun Y, Long B. Application of CMV-IVIg as prophylaxis against cytomegalovirus reactivation in allogeneic hematopoietic stem cell transplantation patients. Clin Transplant 2024; 38:e15300. [PMID: 38555576 DOI: 10.1111/ctr.15300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/21/2024] [Accepted: 03/14/2024] [Indexed: 04/02/2024]
Abstract
Cytomegalovirus (CMV) reactivation remains one of the major and life-threatening complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Yet, there is still a lack of safe and effective ways to prevent CMV reactivation in allo-HSCT patients. Here, we retrospectively analyzed a cohort of patients who underwent HSCT at our transplant center between 2018 and 2022 to evaluate the efficacy of prophylactic CMV-specific intravenous immunoglobulin (CMV-IVIg) against CMV reactivation. After Propensity Score Matching, the CMV reactivation rate was significantly decreased in the CMV-IVIg group (HR, 2.952; 95% CI,1.492-5.841; P = .002) compared with the control group. Additionally, the time duration of CMV reactivation (P = .001) and bacterial infection rate (P = .013) were significantly lower in the CMV-IVIg group. Moreover, prophylactic CMV-IVIg was more effective in CMV seropositive patients who received ATG as part of GVHD prevention (HR, 8.225; 95% CI,1.809-37.39; P = .006). In conclusion, CMV-IVIg is considered an effective and safe way to prevent CMV reactivation in HSCT recipients, which may be related to the acceleration of immune reconstitution in the early stage after transplantation.
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Affiliation(s)
- Jiaqi Cui
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yuhang Zhou
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Gastroenterology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Kui Zhao
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xudong Li
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hanyue Zhang
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiangzhong Zhang
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanling Sun
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bing Long
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Monday LM, Keri V, Chandrasekar PH. Advances in pharmacotherapies for cytomegalovirus infection: what is the current state of play? Expert Opin Pharmacother 2024; 25:685-694. [PMID: 38717943 DOI: 10.1080/14656566.2024.2353627] [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: 01/18/2024] [Accepted: 05/07/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) remains a serious opportunistic infection in hematopoietic cell transplant (HCT) and solid-organ transplant (SOT) recipients. Traditional anti-CMV drugs are limited by toxicities and the development of resistance. Letermovir and maribavir are newly approved antivirals for the prevention and treatment of CMV. AREAS COVERED Prior reviews have discussed use of letermovir for prevention of CMV after HCT and maribavir for resistant or refractory (R/R) CMV post HCT or SOT. Subsequent data have expanded their use including letermovir for primary CMV prophylaxis in high-risk renal transplant recipients and new recommendations for extending prophylaxis through day + 200 in certain HCT patients. Data on the use of maribavir for first asymptomatic CMV infection post-HCT has also been published. This review compares the pharmacology of anti-CMV agents and discusses the updated literature of these new drugs in the prevention and treatment of CMV. EXPERT OPINION Letermovir and maribavir are much needed tools that spare toxicities of ganciclovir, foscarnet, and cidofovir. High cost is a challenge preventing their integration into clinical practice in resource-limited countries. Transplant centers need to exercise restraint in overuse to avoid resistance, particularly in the setting of high viral loads.
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Affiliation(s)
- Lea M Monday
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Vishakh Keri
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
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17
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Schultz BG, Bullano M, Paratane D, Rajagopalan K. Cytomegalovirus related hospitalization costs among hematopoietic stem cell and solid organ transplant recipients treated with maribavir versus investigator-assigned therapy: A US-based study. Transpl Infect Dis 2024; 26:e14216. [PMID: 38221739 DOI: 10.1111/tid.14216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/19/2023] [Accepted: 12/02/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) infections among hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients impose a significant health care resource utilization (HCRU)-related economic burden. Maribavir (MBV), a novel anti-viral therapy (AVT), approved by the United States Food and Drug Administration for post-transplant CMV infections refractory (with/without resistance) to conventional AVTs has demonstrated lower hospital length of stay (LOS) versus investigator-assigned therapy (IAT; valgancilovir, ganciclovir, foscarnet, or cidofovir) in a phase 3 trial (SOLSTICE). This study estimated the HCRU costs of MBV versus IAT. METHODS An economic model was developed to estimate HCRU costs for patients treated with MBV or IAT. Mean per-patient-per-year (PPPY) HCRU costs were calculated using (i) annualized mean hospital LOS in SOLSTICE, and (ii) CMV-related direct costs from published literature. Probabilistic sensitivity analysis with Monte-Carlo simulations assessed model robustness. RESULTS Of 352 randomized patients receiving MBV (n = 235) or IAT (n = 117) for 8 weeks in SOLSTICE, 40% had HSCT and 60% had SOT. Mean overall PPPY HCRU costs of overall hospital-LOS were $67,205 (95% confidence interval [CI]: $33,767, $231,275) versus $145,501 (95% CI: $62,064, $589,505) for MBV and IAT groups, respectively. Mean PPPY ICU and non-ICU stay costs were: $32,231 (95% CI: $5,248, $184,524) versus $45,307 (95% CI: $3,957, $481,740) for MBV and IAT groups, and $82,237 (95% CI: $40,397, $156,945) MBV versus $228,329 (95% CI: $94,442, $517,476) for MBV and IAT groups, respectively. MBV demonstrated cost savings in over 99.99% of simulations. CONCLUSIONS This analysis suggests that Mean PPPY HCRU costs were 29%-64% lower with MBV versus other-AVTs.
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Affiliation(s)
- Bob G Schultz
- US Medical Affairs Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | - Michael Bullano
- US Medical Affairs Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | - Deepika Paratane
- Health Economics and Outcomes Research, Anlitiks, Inc., Windermere, Florida, USA
| | - Krithika Rajagopalan
- Health Economics and Outcomes Research, Anlitiks, Inc., Windermere, Florida, USA
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18
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Groll AH, Schulte JH, Antmen AB, Fraser CJ, Teal VL, Haber B, Caro L, McCrea JB, Fancourt C, Patel M, Menzel K, Badshah C. Pharmacokinetics, Safety, and Efficacy of Letermovir for Cytomegalovirus Prophylaxis in Adolescent Hematopoietic Cell Transplantation Recipients. Pediatr Infect Dis J 2024; 43:203-208. [PMID: 38241643 DOI: 10.1097/inf.0000000000004208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
INTRODUCTION Letermovir is a cytomegalovirus (CMV) terminase complex inhibitor approved for prophylaxis of CMV infection and disease in adult CMV-seropositive allogeneic hematopoietic cell transplantation (allo-HCT) recipients (R+). We report pharmacokinetics (PK), safety, and efficacy of letermovir in adolescent (12-18 years) allogeneic HCT recipients from an ongoing clinical study. METHODS In this phase 2b, multicenter, open-label study (NCT03940586), 28 adolescents received 480 mg letermovir [240 mg with cyclosporin A (CsA)] once daily orally or intravenously. Blood was collected for intensive (n = 14) plasma concentrations of letermovir. Intensive PK data were used for dose confirmation. Target exposure range 34,400-100,000 h × ng/mL for pediatric median exposures was based on model-predicted phase 3 population PK simulations in adult HCT recipients. RESULTS All participants were CMV-seropositive (body weight 28.7-95.0 kg). Of 12 PK-evaluable participants, 8 receiving 480 mg letermovir without CsA and 4 receiving 240 mg letermovir with CsA achieved exposures comparable to the adult exposure range. Exposure above the target but below the adult clinical program maximum was observed in 1 patient. Safety was consistent with previously described safety in adults. The proportion of participants with clinically significant CMV infection through week 24 post-HCT was comparable (24%) to that in the pivotal phase 3 study in adults (37.5%). CONCLUSIONS Administration of adult letermovir doses in this adolescent cohort resulted in exposures within adult clinical program margins and was associated with safety and efficacy similar to adults. Results support a letermovir dose of 480 mg (240 mg with CsA) in adolescent allo-HCT recipients.
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Affiliation(s)
- Andreas H Groll
- From the Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Johannes H Schulte
- Department of Pediatrics, Division of Oncology and Hematology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ali Bülent Antmen
- Department of Pediatric Hematology/Oncology and Bone Marrow Transplantation, Acibadem Adana Hospital, Adana, Turkey
| | - Christopher J Fraser
- Blood and Marrow Transplant Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
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19
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Chaudhry MZ, Borkner L, Kulkarni U, Berberich-Siebelt F, Cicin-Sain L. NFAT signaling is indispensable for persistent memory responses of MCMV-specific CD8+ T cells. PLoS Pathog 2024; 20:e1012025. [PMID: 38346075 PMCID: PMC10890734 DOI: 10.1371/journal.ppat.1012025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/23/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
Cytomegalovirus (CMV) induces a unique T cell response, where antigen-specific populations do not contract, but rather inflate during viral latency. It has been proposed that subclinical episodes of virus reactivation feed the inflation of CMV-specific memory cells by intermittently engaging T cell receptors (TCRs), but evidence of TCR engagement has remained lacking. Nuclear factor of activated T cells (NFAT) is a family of transcription factors, where NFATc1 and NFATc2 signal downstream of TCR in mature T lymphocytes. We show selective impacts of NFATc1 and/or NFATc2 genetic ablations on the long-term inflation of MCMV-specific CD8+ T cell responses despite largely maintained responses to acute infection. NFATc1 ablation elicited robust phenotypes in isolation, but the strongest effects were observed when both NFAT genes were missing. CMV control was impaired only when both NFATs were deleted in CD8+ T cells used in adoptive immunotherapy of immunodeficient mice. Transcriptome analyses revealed that T cell intrinsic NFAT is not necessary for CD8+ T cell priming, but rather for their maturation towards effector-memory and in particular the effector cells, which dominate the pool of inflationary cells.
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Affiliation(s)
- M. Zeeshan Chaudhry
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Lisa Borkner
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Upasana Kulkarni
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | | | - Luka Cicin-Sain
- Department of Viral Immunology, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Centre for Individualized Infection Medicine, a joint venture of Helmholtz Centre for Infection Research and Medical School Hannover, Hannover, Germany
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20
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Klejmont LM, Mo X, Milner J, Harrison L, Morris E, van de Ven C, Cairo MS. Risk Factors Associated with Survival Following Ganciclovir Prophylaxis through Day +100 in Cytomegalovirus At-Risk Pediatric Allogeneic Stem Cell Transplantation Recipients: Development of Cytomegalovirus Viremia Associated with Significantly Decreased 1-Year Survival. Transplant Cell Ther 2024; 30:103.e1-103.e8. [PMID: 37806447 DOI: 10.1016/j.jtct.2023.09.025] [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: 01/19/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/10/2023]
Abstract
Cytomegalovirus (CMV) reactivation is a major cause of morbidity and nonrelapse mortality (NRM) in pediatric allogeneic stem cell transplantation (alloSCT) recipients. Approximately 80% of CMV seropositive alloHCT recipients will experience CMV reactivation without prophylaxis. The impacts of ganciclovir prophylaxis and subsequent CMV viremia on 1-year survival and 1-year NRM are unknown. The primary objective of this study was to determine the effect of CMV viremia on the probability of 1-year survival and 1-year NRM in pediatric alloSCT recipients receiving 100 days of ganciclovir prophylaxis. The secondary objective was to determine the effect of other risk factors on 1-year survival and 1-year NRM. All patients age 0 to 26 years who underwent alloSCT between June 2011 and May 2020 and received ganciclovir prophylaxis for 100 days at Westchester Medical Center, an academic medical center, were analyzed. Ganciclovir was administered to at-risk alloSCT recipients (donor and or recipient CMV+ serostatus) as 5 mg/kg every 12 hours from the first day of conditioning through day -1 (recipient CMV+ only) followed by 6 mg/kg every 24 hours on Monday through Friday beginning on the day of an absolute neutrophil count >750/mm3 and continuing through day +100. National Cancer Institute Common Terminology Criteria for Adverse Events 5.0 criteria were used to grade toxicity. NRM was analyzed using competing survival analysis with relapse death as a competing event. The log-rank and Gray tests were performed to compare the 1-year survival probabilities and NRM cumulative incidence between patients who experienced CMV viremia post-alloSCT and those who did not. Univariate Cox regression analysis was performed for the following risk factors: CMV viremia, donor source, sex, malignant disease, disease risk index, conditioning intensity, receipt of rabbit antithymocyte globulin (rATG)/alemtuzumab, graft-versus-host disease (GVHD) prophylaxis, CMV donor/recipient serostatus, grade II-IV acute GVHD, and grade 3/4 neutropenia necessitating discontinuation of ganciclovir, treating the last 3 factors as time-dependent covariates. Those with P values < .2 were included in the multivariate Cox regression analysis. Eighty-four alloSCT recipients (41 males, 43 females; median age, 10.8 years [range, .4 to 24.4 years]) were analyzed. Multivariate analysis showed significantly lower 1-year survival and significantly higher 1-year NRM in patients who developed CMV viremia compared to those who did not (P = .0036). No other risk factors were significantly associated with 1-year survival or 1-year NRM. One-year survival was significantly decreased and 1-year NRM was significantly increased in pediatric alloSCT recipients who developed CMV viremia following ganciclovir prophylaxis. No other risk factors were found to be associated with 1-year survival or 1-year NRM. Alternative CMV prophylaxis regimens that reduce CMV viremia should be investigated in pediatric alloSCT recipients at risk for CMV infection.
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Affiliation(s)
- Liana M Klejmont
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Xiaokui Mo
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Jordan Milner
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Lauren Harrison
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | - Erin Morris
- Department of Pediatrics, New York Medical College, Valhalla, New York
| | | | - Mitchell S Cairo
- Department of Pediatrics, New York Medical College, Valhalla, New York; Department of Medicine, New York Medical College, Valhalla, New York; Department of Pathology, New York Medical College, Valhalla, New York; Department of Microbiology & Immunology, New York Medical College, Valhalla, New York; Department of Cell Biology & Anatomy, New York Medical College, Valhalla, New York.
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21
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Hinman B, Cox J, Umoru G, Kamble R, Musick W. Extended duration letermovir in allogeneic hematopoietic stem cell transplant. Transpl Immunol 2023; 81:101936. [PMID: 37770000 DOI: 10.1016/j.trim.2023.101936] [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: 03/16/2023] [Revised: 09/17/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Despite the use of antiviral prophylaxis in recipients of allogeneic hematopoietic cell transplants (HCT), cytomegalovirus (CMV) is a common clinically significant infection and is associated with significant morbidity and mortality in this patient population. Based on current approval, letermovir is initiated within 28 days following allogeneic HCT for CMV seropositive recipients and continued through 100 days post-transplant. However, it is unknown whether patients who receive extended duration CMV prophylaxis with letermovir would result in less CMV reactivation and reactivation compared to those who do not. This study aimed to evaluate the efficacy of letermovir prophylaxis in CMV seropositive patients when continued for greater than 100 days post-allogeneic stem cell transplant. METHODS A single-center retrospective chart review was conducted on recipients of allogeneic HCT from November 2017 to July 2021. Patients were eligible for inclusion if they were at least 18 years of age, received an allogeneic HCT, CMV seropositive, and initiated letermovir between days 0-28 post-transplant. The primary endpoint of this study is to compare rates of CMV reactivation in patients who stopped letermovir prophylaxis at 100 days post-transplant (standard duration group) versus those who continued letermovir prophylaxis past day 100 (extended duration group). RESULTS A total of 87 patients met the eligibility criteria for inclusion. The median duration of letermovir prophylaxis was 78 days in the standard duration group versus and 132 days in the extended duration group. There were more CMV reactivations in the standard duration group versus the extended duration group, 28% versus 19% respectively. CMV pneumonitis was observed in one of the patients in the standard duration group. All-cause mortality at day 200 post-transplant was similar between the two groups. CONCLUSION The results of this study suggest that extended duration letermovir prophylaxis may be associated with less CMV reactivation compared to the standard duration of prophylaxis.
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Affiliation(s)
- Breanna Hinman
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - James Cox
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - Godsfavour Umoru
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - Rammurti Kamble
- Center for Cell and Gene Therapy, Baylor College of Medicine and Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
| | - Will Musick
- Houston Methodist Hospital, 6565 Fannin St., Houston, TX 77054, USA.
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22
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Stern L, McGuire HM, Avdic S, Blyth E, Gottlieb D, Patrick E, Abendroth A, Slobedman B. Circulating cytokine and chemokine patterns associated with cytomegalovirus reactivation after stem cell transplantation. Clin Transl Immunology 2023; 12:e16815. [PMID: 38034080 PMCID: PMC10684332 DOI: 10.1002/cti2.1473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/31/2023] [Accepted: 11/01/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives Human cytomegalovirus (HCMV) reactivation is the leading viral complication after allogeneic haematopoietic stem cell transplantation (allo-HSCT). Understanding of circulating cytokine/chemokine patterns which accompany HCMV reactivation and correlate with HCMV DNAemia magnitude is limited. We aimed to characterise plasma cytokine/chemokine profiles in 36 allo-HSCT patients (21 with HCMV reactivation and 15 without HCMV reactivation) at four time-points in the first 100-day post-transplant. Methods The concentrations of 31 cytokines/chemokines in plasma samples were analysed using a multiplex bead-based immunoassay. Cytokine/chemokine concentrations were compared in patients with high-level HCMV DNAemia, low-level HCMV DNAemia or no HCMV reactivation, and correlated with immune cell frequencies measured using mass cytometry. Results Increased plasma levels of T helper 1-type cytokines/chemokines (TNF, IL-18, IP-10, MIG) were detected in patients with HCMV reactivation at the peak of HCMV DNAemia, relative to non-reactivators. Stem cell factor (SCF) levels were significantly higher before the detection of HCMV reactivation in patients who went on to develop high-level HCMV DNAemia (810-52 740 copies/mL) vs. low-level HCMV DNAemia (< 250 copies/mL). High-level HCMV reactivators, but not low-level reactivators, developed an elevated inflammatory cytokine/chemokine profile (MIP-1α, MIP-1β, TNF, LT-α, IL-13, IL-9, SCF, HGF) at the peak of reactivation. Plasma cytokine concentrations displayed unique correlations with circulating immune cell frequencies in patients with HCMV reactivation. Conclusion This study identifies distinct circulating cytokine/chemokine signatures associated with the magnitude of HCMV DNAemia and the progression of HCMV reactivation after allo-HSCT, providing important insight into immune recovery patterns associated with HCMV reactivation and viral control.
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Affiliation(s)
- Lauren Stern
- Infection, Immunity and Inflammation, School of Medical Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
- Charles Perkins CentreThe University of SydneySydneyNSWAustralia
| | - Helen M McGuire
- Infection, Immunity and Inflammation, School of Medical Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
- Charles Perkins CentreThe University of SydneySydneyNSWAustralia
| | - Selmir Avdic
- Westmead Institute for Medical ResearchThe University of SydneySydneyNSWAustralia
| | - Emily Blyth
- Westmead Institute for Medical ResearchThe University of SydneySydneyNSWAustralia
- Blood Transplant and Cell Therapies Program, Department of HaematologyWestmead HospitalSydneyNSWAustralia
- Faculty of Medicine and Health, Sydney Medical SchoolThe University of SydneySydneyNSWAustralia
| | - David Gottlieb
- Westmead Institute for Medical ResearchThe University of SydneySydneyNSWAustralia
- Blood Transplant and Cell Therapies Program, Department of HaematologyWestmead HospitalSydneyNSWAustralia
- Faculty of Medicine and Health, Sydney Medical SchoolThe University of SydneySydneyNSWAustralia
| | - Ellis Patrick
- Westmead Institute for Medical ResearchThe University of SydneySydneyNSWAustralia
- School of Mathematics and StatisticsThe University of SydneySydneyNSWAustralia
| | - Allison Abendroth
- Infection, Immunity and Inflammation, School of Medical Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
- Charles Perkins CentreThe University of SydneySydneyNSWAustralia
| | - Barry Slobedman
- Infection, Immunity and Inflammation, School of Medical Sciences, Faculty of Medicine and HealthThe University of SydneySydneyNSWAustralia
- Charles Perkins CentreThe University of SydneySydneyNSWAustralia
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23
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Souan L, Jazar HA, Nashwan S, Sughayer MA. QuantiFERON-CMV and monitor predict cytomegalovirus, mortality, and graft-versus-host disease in transplant recipients. J Med Virol 2023; 95:e29250. [PMID: 38009250 DOI: 10.1002/jmv.29250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 11/28/2023]
Abstract
Cytomegalovirus (CMV) is the most prevalent infection in recipients of hematopoietic stem cell transplant (HSCT). QuantiFERON-CMV (QF-CMV) and QuantiFERON-Monitor (QFM) assays were used to test whether immune-competent adult allogeneic HSCT recipients with CMV-specific T cells can control CMV infection or reactivation. Our data demonstrated a significant correlation between CMV infection measured by CMV-antigenemia test and QF-CMV results, graft versus host disease (GvHD), and mortality rates. The QF-CMV test revealed that CMV-specific T cells with higher interferon-γ (IFN-γ) release were correlated with lower CMV infection rates. There was a significant negative association between QF-CMV results, GvHD, and mortality rates. Data showed that a one-unit rise in IFN-γ was linked with a 12.7% reduction in GvHD and a 20.7% reduction in the mortality odds ratio. In addition, a negative correlation was found between QF-M results and CMV infection, with the QFM test predicting protection against CMV infection by 1.9%. This is one of the few studies establishing the QF-CMV test's predictive value for GvHD and mortality, its use to monitor HSCT patients for pre-emptive therapy, and the use of the QFM test to predict CMV infection and mortality in HSCT patients. Thus, these assays could be utilized to optimize preventive and pre-emptive therapy procedures to reduce transplant recipient adverse effects and posttransplant therapy costs.
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Affiliation(s)
- Lina Souan
- Department of Pathology & Laboratory Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Husam Abu Jazar
- Bone Marrow and Stem Cell Transplantation Program, King Hussein Cancer Center, Amman, Jordan
| | - Sura Nashwan
- Department of Pathology & Laboratory Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Maher A Sughayer
- Department of Pathology & Laboratory Medicine, King Hussein Cancer Center, Amman, Jordan
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24
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Kabut T, Weinbergerová B, Folber F, Lengerová M, Mayer J. High-dose aciclovir in CMV infection prophylaxis after allogeneic HSCT: a single-center long-term experience. Bone Marrow Transplant 2023; 58:1229-1236. [PMID: 37612466 PMCID: PMC10622319 DOI: 10.1038/s41409-023-02081-6] [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: 01/25/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 08/25/2023]
Abstract
There is only limited data on cytomegalovirus (CMV) prophylaxis with high-dose (HD) aciclovir after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We performed a retrospective analysis on a total of 179 patients who underwent their allo-HSCT with HD-aciclovir prophylaxis at our center. A clinically significant CMV infection (cs-CMVi) was observed in 56 (31%) cases with a median time of 49 (range 25-147) days after HSCT. A significantly higher CMV infection rate was observed in seropositive recipients with a seronegative donor (74%) compared to seropositive recipients with a seropositive donor, and seronegative recipients with seropositive and seronegative donors (24%, 18%, 7% respectively; p < 0.001). The CMV serostatus was the only significant risk factor for CMV infection in our analysis. CMV disease developed in three patients with CMV-related death in two cases. During HD-aciclovir prophylaxis, we did not observe any medical condition attributable to HD-aciclovir's adverse effects. Compared to published results, we observed a low incidence of cs-CMVi with HD-aciclovir prophylaxis in several patient subgroups, especially in seropositive recipients with a seropositive donor. With respect to the determined threshold, HD-aciclovir prophylaxis seems to have good efficacy in an intermediate cs-CMVi risk patients, but prospective randomized trials would be needed for definite conclusions.
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Affiliation(s)
- Tomáš Kabut
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Barbora Weinbergerová
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic.
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - František Folber
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martina Lengerová
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Mayer
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
- Department of Internal Medicine-Hematology and Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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25
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Dirck A, Diggins NL, Crawford LB, Perez WD, Parkins CJ, Struthers HH, Turner R, Pham AH, Mitchell J, Papen CR, Malouli D, Hancock MH, Caposio P. HCMV UL8 interaction with β-catenin and DVL2 regulates viral reactivation in CD34 + hematopoietic progenitor cells. J Virol 2023; 97:e0124123. [PMID: 37772824 PMCID: PMC10617580 DOI: 10.1128/jvi.01241-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 09/30/2023] Open
Abstract
IMPORTANCE CD34+ hematopoietic progenitor cells (HPCs) are an important cellular reservoir for latent human cytomegalovirus (HCMV). Several HCMV genes are expressed during latency that are involved with the maintenance of the viral genome in CD34+ HPC. However, little is known about the process of viral reactivation in these cells. Here, we describe a viral protein, pUL8, and its interaction and stabilization with members of the Wnt/β-catenin pathway as an important component of viral reactivation. We further define that pUL8 and β-catenin interact with DVL2 via a PDZ-binding domain, and loss of UL8 interaction with β-catenin-DVL2 restricts viral reactivation. Our findings will be instrumental in understanding the molecular processes involved in HCMV reactivation in order to design new antiviral therapeutics.
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Affiliation(s)
- Aaron Dirck
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Nicole L. Diggins
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Lindsey B. Crawford
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Wilma D. Perez
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Christopher J. Parkins
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Hillary H. Struthers
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Rebekah Turner
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Andrew H. Pham
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Jennifer Mitchell
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Courtney R. Papen
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Daniel Malouli
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Meaghan H. Hancock
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Patrizia Caposio
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
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26
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Abidi MZ, Molina KC, Garth K, Gutman JA, Weinberg A. Cytomegalovirus Immune reconstitution in cord blood transplant recipients on letermovir prophylaxis. Transpl Infect Dis 2023; 25:e14104. [PMID: 37436771 PMCID: PMC10592381 DOI: 10.1111/tid.14104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/21/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Cytomegalovirus (CMV) can cause significant morbidity and mortality in cord blood transplant (CBT) recipients. Development of CMV-specific cell-mediated immunity (CMV-CMI) has been associated with protection against CMV clinically significant reactivation (CsCMV). In this study, we evaluated CMV-CMI reconstitution during letermovir prophylactic therapy, which prevents CsCMV without complete suppression of CMV reactivation. METHODS We measured CMV-CMI in CMV-seropositive CBT recipients pre-transplant after Day+90 of letermovir prophylaxis and at Days +180, and +360- post-transplant using a dual color CMV-specific IFNγ/IL2 FLUOROSpot. CsCMV and nonCsCMV reactivations were abstracted from medical records. CsCMV was defined as CMV viral load ≥5,000 IU/ml using a whole blood assay. RESULTS Among 70 CBT recipients, 31 developed CMV-CMI by Day+90 and an additional eight and five participants by Days +180 and +360, respectively. Thirty-eight participants developed CMV reactivation, including nine with CsCMV. Most reactivations (33 of 38) occurred before Day+180. Early CMV-CMI was present in six out of nine participants with CsCMV, indicating a lack of protection against CsCMV. Moreover, the magnitude of CMV-CMI at Day+90 did not differ between participants with CsCMV and nonCsCMV. CONCLUSION Approximately 50% of CBT recipients reconstituted CMV-CMI during letermovir prophylactic therapy. However, CMV-CMI did not reach levels protective against CsCMV. Extension of CMV prophylaxis beyond Day+90 may be considered in CMV-seropositive CBT recipients.
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Affiliation(s)
- Maheen Z. Abidi
- Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, US
| | - Kyle C. Molina
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Pharmacy, Scripps Green Hospital, La Jolla, CA, USA
| | - Krystle Garth
- Division of Infectious Diseases, Departments of Pediatrics, University of Colorado, Denver, CO, USA
| | - Jonathan A. Gutman
- Department of Hematology Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adriana Weinberg
- Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, US
- Division of Infectious Diseases, Departments of Pediatrics, University of Colorado, Denver, CO, USA
- Department of Pathology, University of Colorado, Aurora, CO USA
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27
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Kang KW, Jeon MJ, Yu ES, Kim DS, Lee BH, Lee SR, Choi CW, Park Y, Kim BS, Sung HJ. Cytomegalovirus reactivation under pre-emptive therapy following allogeneic hematopoietic stem cell transplant: Pattern, survival, and risk factors in the Republic of Korea. PLoS One 2023; 18:e0291268. [PMID: 37703263 PMCID: PMC10499250 DOI: 10.1371/journal.pone.0291268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023] Open
Abstract
INTRODUCTION Pre-emptive therapy for cytomegalovirus (CMV) reactivation has been used in allogeneic hematopoietic stem cell transplantation (allo-HSCT). It is unclear if this strategy has poorer clinical outcomes in CMV-endemic areas and if more aggressive prophylaxis is required. METHODS We retrospectively analyzed the patterns and survival after CMV reactivation in patients undergoing pre-emptive therapy following allo-HSCT and assessed high-risk patients who could benefit from aggressive CMV prophylaxis in endemic areas. RESULTS Of the 292 patients who underwent allo-HSCT, 70.5% (donor+ or recipient+) were CMV seropositive. CMV reactivation occurred in 139 patients (47.6%), with a median of 31.5 days from day 0 of allo-HSCT. The overall survival of patients with CMV reactivation who received pre-emptive therapy did not differ from those without reactivation. Of the 139 patients with CMV reactivation, 78 (56.1%) underwent ≥2 rounds of pre-emptive therapy. In multivariate analysis, the risk of CMV reactivation was higher in patients with multiple myeloma, with CMV seropositivity of the recipient and donor, administered with a higher dose of anti-thymocyte globulin (ATG), and with acute graft-versus-host disease (aGVHD) ≥ grade 2. CONCLUSION Although half of the patients with allo-HSCT were administered with pre-emptive therapy for CMV, CMV reactivation did not affect their survival, indicating the advantages of pre-emptive therapy, even in CMV-endemic areas. The cost-effectiveness of more aggressive CMV prophylaxis should be re-evaluated in patients at a high risk for CMV reactivation.
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Affiliation(s)
- Ka-Won Kang
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Ji Jeon
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eun Sang Yu
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Dae Sik Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung-Hyun Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Se Ryeon Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Chul Won Choi
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yong Park
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Soo Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hwa Jung Sung
- Division of Hematology-Oncology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Perrotta C, Fenizia C, Carnovale C, Pozzi M, Trabattoni D, Cervia D, Clementi E. Updated Considerations for the Immunopharmacological Aspects of the "Talented mRNA Vaccines". Vaccines (Basel) 2023; 11:1481. [PMID: 37766157 PMCID: PMC10534931 DOI: 10.3390/vaccines11091481] [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: 08/21/2023] [Revised: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
Messenger RNA (mRNA) vaccines belong to a new class of medications, RNA therapeutics, including both coding and non-coding RNAs. The use of mRNA as a therapy is based on the biological role of mRNA itself, namely its translation into a functional protein. The goal of mRNA vaccines is to produce a specific antigen in cells to elicit an immune response that might be prophylactic or therapeutic. The potential of mRNA as vaccine has been envisaged for years but its efficacy has been clearly demonstrated with the approval of COVID-19 vaccines in 2021. Since then, mRNA vaccines have been in the pipeline for diseases that are still untreatable. There are many advantages of mRNA vaccines over traditional vaccines, including easy and cost-effective production, high safety, and high-level antigen expression. However, the nature of mRNA itself and some technical issues pose challenges associated with the vaccines' development and use. Here we review the immunological and pharmacological features of mRNA vaccines by discussing their pharmacokinetics, mechanisms of action, and safety, with a particular attention on the advantages and challenges related to their administration. Furthermore, we present an overview of the areas of application and the clinical trials that utilize a mRNA vaccine as a treatment.
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Affiliation(s)
- Cristiana Perrotta
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, 20157 Milano, Italy; (C.C.); (D.T.)
| | - Claudio Fenizia
- Department of Pathophysiology and Transplantation (DEPT), Università degli Studi di Milano, 20122 Milano, Italy;
| | - Carla Carnovale
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, 20157 Milano, Italy; (C.C.); (D.T.)
| | - Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy;
| | - Daria Trabattoni
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, 20157 Milano, Italy; (C.C.); (D.T.)
| | - Davide Cervia
- Department for Innovation in Biological, Agro-Food and Forest Systems (DIBAF), Università degli Studi della Tuscia, 01100 Viterbo, Italy;
| | - Emilio Clementi
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, 20157 Milano, Italy; (C.C.); (D.T.)
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Italy;
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29
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Rasmussen KK, dos Santos Q, MacPherson CR, Zucco AG, Gjærde LK, Ilett EE, Lodding I, Helleberg M, Lundgren JD, Nielsen SD, Brix S, Sengeløv H, Murray DD. Metabolic Profiling Early Post-Allogeneic Haematopoietic Cell Transplantation in the Context of CMV Infection. Metabolites 2023; 13:968. [PMID: 37755248 PMCID: PMC10536708 DOI: 10.3390/metabo13090968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 09/28/2023] Open
Abstract
Immune dysfunction resulting from allogeneic haematopoietic stem cell transplantation (aHSCT) predisposes one to an elevated risk of cytomegalovirus (CMV) infection. Changes in metabolism have been associated with adverse outcomes, and in this study, we explored the associations between metabolic profiles and post-transplantation CMV infection using plasma samples collected 7-33 days after aHSCT. We included 68 aHSCT recipients from Rigshospitalet, Denmark, 50% of whom experienced CMV infection between days 34-100 post-transplantation. First, we investigated whether 12 metabolites selected based on the literature were associated with an increased risk of post-transplantation CMV infection. Second, we conducted an exploratory network-based analysis of the complete metabolic and lipidomic profiles in relation to clinical phenotypes and biological pathways. Lower levels of trimethylamine N-oxide were associated with subsequent CMV infection (multivariable logistic regression: OR = 0.63; 95% CI = [0.41; 0.87]; p = 0.01). Explorative analysis revealed 12 clusters of metabolites or lipids, among which one was predictive of CMV infection, and the others were associated with conditioning regimens, age upon aHSCT, CMV serostatus, and/or sex. Our results provide evidence for an association between the metabolome and CMV infection post-aHSCT that is independent of known risk factors.
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Affiliation(s)
- Kirstine K. Rasmussen
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Quenia dos Santos
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Cameron Ross MacPherson
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Adrian G. Zucco
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Lars Klingen Gjærde
- Bone Marrow Transplant Unit, Department of Hematology, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Emma E. Ilett
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
- Center for Basic Metabolic Research (CBMR), Copenhagen University, Blegdamsvej 3, 2200 Copenhagen, Denmark
| | - Isabelle Lodding
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Marie Helleberg
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Jens D. Lundgren
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Susanne D. Nielsen
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Susanne Brix
- DTU Bioengineering, Department of Biotechnology and Biomedicine, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
| | - Henrik Sengeløv
- Bone Marrow Transplant Unit, Department of Hematology, Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
| | - Daniel D. Murray
- Centre of Excellence for Health, Immunity and Infections (CHIP), Rigshospitalet, Copenhagen University Hospital, 2100 Copenhagen, Denmark
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30
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Iftikhar R, Farhan M, Khan M, Chaudhry QUN, Ghafoor T, Shahbaz N, Khan MA, Khattak TA, Rehman J, Humayun S, Majeed A. Cytomegalovirus Infection Post-Allogeneic Stem Cell Transplantation: Experience from a Country with High Seropositivity. Transplant Cell Ther 2023; 29:521.e1-521.e7. [PMID: 37164292 DOI: 10.1016/j.jtct.2023.04.023] [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: 12/20/2022] [Revised: 04/27/2023] [Accepted: 04/30/2023] [Indexed: 05/12/2023]
Abstract
Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). Limited data are available from developing countries regarding the frequency of CMV infection and treatment outcomes. We enrolled 230 consecutive patients undergoing allogeneic HSCT for various hematologic disorders at the Armed Forces Bone Marrow Transplant Center/National Institute of Blood And Marrow Transplant between February 2017 and December 202. CMV reactivation post-HSCT was monitored weekly starting at day +30 and continuing until day +100, and preemptive antiviral therapy was administered to prevent CMV disease in all HSCT recipients with ≥2000 CMV copies/mL. The median age of the study cohort was 9.5 years (range, .6 to 53 years), and the male:female ratio was 2.4:1. The most frequent indication for HSCT was beta thalassemia major (36.1%), followed by aplastic anemia (23.9%). Malignant disorders constituted 20% of all the patients. Pretransplantation CMV seropositivity was 99.1% for the recipients and 99.5% for the donors. CMV infection was seen in 66.1% of the patients, and the median time to CMV DNAemia was 36 days (range, 12 to 95 days). Preemptive antiviral therapy was administered to 140 patients with a CMV viral load ≥2000 copies/mL (61%). In multivariate analysis, patient age >12 years, steroid administration, and use of mycophenolate mofetil with or without post-transplantation cyclophosphamide was associated with the greatest probability of CMV reactivation. Overall survival was 97.4% in patients without CMV reactivation, compared to 80.3% in those with CMV reactivation (P = .001). Event-free survival was 78.7% in the total study cohort, including 89.7% for patients without CMV reactivation and 73% for patients with CMV reactivation (P = .003). Our study is the first from this region to explore the frequency of CMV seropositivity and CMV infection, risk factors for CMV reactivation, and outcomes of antiviral therapy in HSCT recipients.
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Affiliation(s)
- Raheel Iftikhar
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan.
| | - Muhammad Farhan
- Department of Hematology and Stem Cell Transplant, Gambat Institute of Medical Sciences, Gambat, Pakistan
| | - Maryam Khan
- Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan
| | - Qamar Un Nisa Chaudhry
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Ghafoor
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Nighat Shahbaz
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Mehreen Ali Khan
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Tariq Azam Khattak
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Jahanzeb Rehman
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Saima Humayun
- Department of Hematology and Stem Cell Transplant, Armed Forces Bone Marrow Transplant Centre/National Institute of Blood and Marrow Transplant, Rawalpindi, Pakistan
| | - Aneela Majeed
- Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
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31
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Akahoshi Y, Nakasone H, Takenaka K, Yamasaki S, Nakamura M, Doki N, Tanaka M, Ozawa Y, Uchida N, Ara T, Nakamae H, Ota S, Onizuka M, Yano S, Tanaka J, Fukuda T, Kanda Y, Atsuta Y, Kako S, Yanada M, Arai Y. CMV reactivation after allogeneic HCT is associated with a reduced risk of relapse in acute lymphoblastic leukemia. Blood Adv 2023; 7:2699-2708. [PMID: 36661335 PMCID: PMC10333743 DOI: 10.1182/bloodadvances.2022009376] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 01/21/2023] Open
Abstract
Cytomegalovirus reactivation (CMVR) after allogeneic hematopoietic cell transplantation (HCT) is a frequent complication related to survival outcomes; however, its impact on relapse remains unclear, especially in acute lymphoblastic leukemia (ALL). In this nationwide retrospective study, we included patients with acute myeloid leukemia (AML) and ALL in the first or second complete remission who underwent their first HCT using a pre-emptive strategy for CMVR. Because 90% of cases with CMVR had occurred by day 64 and 90% of cases with grades 2 to 4 acute graft-versus-host disease (GVHD) had occurred by day 58, a landmark point was set at day 65. In landmark analyses, 3793 patients with AML and 2213 patients with ALL who survived without relapse for at least 65 days were analyzed. Multivariate analyses showed that CMVR was associated with a lower incidence of relapse in both AML (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.69-0.95; P = .009) and ALL (HR, 0.81; 95% CI, 0.66-0.99; P = .045). These findings were confirmed when CMVR was used as the time-dependent covariate. Moreover, our study suggests that the protective effect of CMVR on relapse was independent of acute GVHD. A post-hoc subgroup analysis of combined AML and ALL showed that CMVR had a mild antileukemia effect without effect modification, in contrast to the impact of CMVR on NRM. Our findings may provide important implications for strategies used for CMV prophylaxis after HCT.
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Affiliation(s)
- Yu Akahoshi
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hideki Nakasone
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Katsuto Takenaka
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Satoshi Yamasaki
- Department of Internal Medicine, Kyushu University Beppu Hospital, Oita, Japan
| | - Momoko Nakamura
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Kanagawa, Japan
| | - Yukiyasu Ozawa
- Department of Hematology, Japanese Red Cross Nagoya First Hospital, Aichi, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Takahide Ara
- Department of Hematology, Hokkaido University Faculty of Medicine, Hokkaido, Japan
| | - Hirohisa Nakamae
- Department of Hematology, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shuichi Ota
- Department of Hematology, Sapporo Hokuyu Hospital, Hokkaido, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Kanagawa, Japan
| | - Shingo Yano
- Clinical Oncology and Hematology, The Jikei University School of Medicine, Tokyo, Japan
| | - Junji Tanaka
- Department of Hematology, Tokyo Women's Medical University, Tokyo, Japan
| | - Takahiro Fukuda
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Aichi, Japan
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Aichi, Japan
| | - Shinichi Kako
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Yanada
- Department of Haematology and Cell Therapy, Aichi Cancer Centre, Aichi, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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32
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Crawford LB. Hematopoietic stem cells and betaherpesvirus latency. Front Cell Infect Microbiol 2023; 13:1189805. [PMID: 37346032 PMCID: PMC10279960 DOI: 10.3389/fcimb.2023.1189805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/11/2023] [Indexed: 06/23/2023] Open
Abstract
The human betaherpesviruses including human cytomegalovirus (HCMV), human herpesvirus (HHV)-6a and HHV-6b, and HHV-7 infect and establish latency in CD34+ hematopoietic stem and progenitor cells (HPCs). The diverse repertoire of HPCs in humans and the complex interactions between these viruses and host HPCs regulate the viral lifecycle, including latency. Precise manipulation of host and viral factors contribute to preferential maintenance of the viral genome, increased host cell survival, and specific manipulation of the cellular environment including suppression of neighboring cells and immune control. The dynamic control of these processes by the virus regulate inter- and intra-host signals critical to the establishment of chronic infection. Regulation occurs through direct viral protein interactions and cellular signaling, miRNA regulation, and viral mimics of cellular receptors and ligands, all leading to control of cell proliferation, survival, and differentiation. Hematopoietic stem cells have unique biological properties and the tandem control of virus and host make this a unique environment for chronic herpesvirus infection in the bone marrow. This review highlights the elegant complexities of the betaherpesvirus latency and HPC virus-host interactions.
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Affiliation(s)
- Lindsey B Crawford
- Department of Biochemistry, University of Nebraska-Lincoln, Lincoln, NE, United States
- Nebraska Center for Virology, University of Nebraska-Lincoln, Lincoln, NE, United States
- Nebraska Center for Integrated Biomolecular Communication, University of Nebraska-Lincoln, Lincoln, NE, United States
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Sepassi A, Saunders IM, Bounthavong M, Taplitz RA, Logan C, Watanabe JH. Cost Effectiveness of Letermovir for Cytomegalovirus Prophylaxis Compared with Pre-Emptive Therapy in Allogeneic Hematopoietic Stem Cell Transplant Recipients in the United States. PHARMACOECONOMICS - OPEN 2023; 7:393-404. [PMID: 36840894 PMCID: PMC10169956 DOI: 10.1007/s41669-023-00398-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/13/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE The aim of this study was to assess the cost effectiveness of letermovir prophylaxis with the option for subsequent pre-emptive therapy (PET) for the prevention of cytomegalovirus (CMV) infection compared with a PET-only scenario in adult allogeneic hematopoietic stem cell transplant (allo-HCT) recipients in the United States over a 10-year time horizon. MATERIALS AND METHODS A publicly available decision tree model was constructed using a commercial third-party payer perspective to simulate an allo-HCT recipient's clinical trajectory in the first-year post-transplant, followed by entry to a Markov model to simulate years 2 through 10. Clinical inputs and utility estimates were derived from published literature. Costs were derived from published literature and US Department of Veterans Affairs Federal Supply Schedule drug pricing. Outcomes assessed included life expectancy, quality-adjusted life-years (QALYs), direct medical costs, and the incremental cost-effectiveness ratio (ICER). One-way and probabilistic sensitivity analyses (PSA) were performed to test the robustness of the findings. RESULTS Compared with PET alone, letermovir prophylaxis was projected to increase life-years per person (4.99 vs. 4.70 life-years), and increase QALYs (3.29 vs. 3.08) and costs (US$83.411 vs. US$70,698), yielding an ICER of US$59,356 per QALY gained. One-way sensitivity analyses indicated our model was sensitive to mortality (ICER: $164,771/QALY) and utility (letermovir ICER: $117,447/QALY; PET ICER: $107,290/QALY) in the first-year post-transplant. In 57.1% of the PSA simulations, letermovir was a cost-effective option using a willingness-to-pay threshold of US$100,000 per QALY. CONCLUSIONS Letermovir prophylaxis is cost effective compared with PET alone with a willingness-to-pay threshold of US$100,000 per QALY gained. Sensitivity analysis results indicate future research is required to understand the impact of mortality and quality of life in the first-year post-transplant to arrive at a conclusive decision on letermovir adoption.
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Affiliation(s)
- Aryana Sepassi
- Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA.
| | - Ila M Saunders
- Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
| | - Mark Bounthavong
- Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
- Department of Veteran Affairs, Health Economic Resource Center, Menlo Park, CA, USA
| | | | - Cathy Logan
- Division of Infectious Diseases and Global Health, University of California, San Diego, La Jolla, CA, USA
| | - Jonathan H Watanabe
- Department of Clinical Pharmacy Practice, University of California, Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA
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La Rosa C, Aldoss I, Park Y, Yang D, Zhou Q, Gendzekhadze K, Kaltcheva T, Rida W, Dempsey S, Arslan S, Artz A, Ball B, Nikolaenko L, Pullarkat VA, Nakamura R, Diamond DJ. Hematopoietic stem cell donor vaccination with cytomegalovirus triplex augments frequencies of functional and durable cytomegalovirus-specific T cells in the recipient: A novel strategy to limit antiviral prophylaxis. Am J Hematol 2023; 98:588-597. [PMID: 36594185 PMCID: PMC10294297 DOI: 10.1002/ajh.26824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023]
Abstract
To enhance protective cytomegalovirus (CMV)-specific T cells in immunosuppressed recipients of an allogeneic hematopoietic cell transplant (HCT), we evaluated post-HCT impact of vaccinating healthy HCT donors with Triplex. Triplex is a viral vectored recombinant vaccine expressing three immunodominant CMV antigens. The vector is modified vaccinia Ankara (MVA), an attenuated, non-replicating poxvirus derived from the vaccinia virus strain Ankara. It demonstrated tolerability and immunogenicity in healthy adults and HCT recipients, in whom it also reduced CMV reactivation. Here, we report feasibility, safety, and immunological outcomes of a pilot phase 1 trial (NCT03560752 at ClinicalTrials.gov) including 17 CMV-seropositive recipients who received an HCT from a matched related donor (MRD) vaccinated with 5.1 × 108 pfu/ml of Triplex before cell harvest (median 15, range 11-28 days). Donor and recipient pairs who committed to participation in the trial resulted in exceptional adherence to the protocol. Triplex was well-tolerated with limited adverse events in donors and recipients, who all engrafted with full donor chimerism. On day 28 post-HCT, levels of functional vaccinia- and CMV-specific CD137+ CD8+ T cells were significantly higher (p < .0001 and p = .0174, respectively) in recipients of Triplex vaccinated MRD than unvaccinated MRD (control cohort). Predominantly, central and effector memory CMV-specific T-cell responses continued to steadily expand through 1-year follow-up. CMV viremia requiring antivirals developed in three recipients (18%). In summary, this novel approach represents a promising strategy applicable to different HCT settings for limiting the use of antiviral prophylaxis, which can impair and delay CMV-specific immunity, leading to CMV reactivation requiring treatment.
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Affiliation(s)
- Corinna La Rosa
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Yoonsuh Park
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Dongyun Yang
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Qiao Zhou
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Ketevan Gendzekhadze
- Histocompatibility Laboratory, Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Teodora Kaltcheva
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | | | - Shannon Dempsey
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Brian Ball
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Liana Nikolaenko
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Vinod A Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Don J. Diamond
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
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Puget L, Berceanu A, Node J, Coaquette A, Overs A, Herbein G, Prétet JL, Daguindau E, Lepiller Q. Human cytomegalovirus-viruria in hematopoietic stem cell transplant recipients: Context and impact. Infect Dis Now 2023; 53:104651. [PMID: 36702306 DOI: 10.1016/j.idnow.2023.104651] [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: 11/16/2022] [Revised: 01/05/2023] [Accepted: 01/15/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Episodes of CMV-viruria have been reported in hematopoietic stem cell transplant (HSCT) recipients, but their context of occurrence, pathophysiology, and clinical significance remain misunderstood. METHODS Uurine samples from 517 recipients were collected. Clinical features of recipients with or without episodes of CMV-viruria were retrospectively compared. RESULTS CMV-viruria was detected in 15.5 % of cases. Age, sex, type of transplantation, HLA-matching, conditioning regimen, and immunosuppressive therapies did not differ between patients with and without CMV-viruria. CMV-seropositive status (R + ) was more frequent among CMV-viruric recipients. Cumulated mortality did not differ between the two groups but graft-versus-host diseases occurred more frequently among CMV-viruric patients (p = 0.04). No reduction of the estimated glomerular filtration rates was observed in CMV-viruric recipients. CONCLUSIONS CMV-viruria primarily occurs in CMV-seropositive recipients and is not related to the degree of immunosuppression. We suggest that CMV-viruria is primarily related to the inability of the graft immune system to contain CMV-replication in R + patients. CMV-viruria is not associated with increased mortality or renal dysfunction.
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Affiliation(s)
- L Puget
- Laboratoire de Virologie, CHU Besançon, France
| | - A Berceanu
- Service d'Hématologie, CHU Besançon, France
| | - J Node
- Laboratoire de Virologie, CHU Besançon, France
| | - A Coaquette
- Laboratoire de Virologie, CHU Besançon, France
| | - A Overs
- Laboratoire de Virologie, CHU Besançon, France
| | - G Herbein
- Laboratoire de Virologie, CHU Besançon, France; EA4266, Université Bourgogne Franche-Comté, France
| | - J-L Prétet
- Laboratoire de Biologie Cellulaire et Moléculaire, CHU Besançon, France; EA3181, Université Bourgogne Franche-Comté, France
| | - E Daguindau
- Service d'Hématologie, CHU Besançon, France; Université Bourgogne Franche-Comté, INSERM, EFS BFC, UMR 1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-25000 Besançon, France
| | - Q Lepiller
- Laboratoire de Virologie, CHU Besançon, France; EA3181, Université Bourgogne Franche-Comté, France.
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Hawks KG, Fegley A, Sabo RT, Roberts CH, Toor AA. High dose valacyclovir for cytomegalovirus prophylaxis following allogeneic hematopoietic cell transplantation. J Oncol Pharm Pract 2023; 29:130-137. [PMID: 34854771 DOI: 10.1177/10781552211060479] [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: 12/15/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) is one of the most common and clinically significant viral infections following allogeneic hematopoietic cell transplantation (HCT). Currently available options for CMV prophylaxis and treatment present challenges related to side effects and cost. METHODS In this retrospective medical record review, the incidence of clinically significant CMV infection (CMV disease or reactivation requiring preemptive treatment) following allogeneic HCT was compared in patients receiving valacyclovir 1 g three times daily versus acyclovir 400 mg every 12 h for viral prophylaxis. RESULTS Forty-five patients who received valacyclovir were matched based on propensity scoring to 35 patients who received acyclovir. All patients received reduced-intensity conditioning regimens containing anti-thymocyte globulin. Clinically significant CMV infection by day + 180 was lower in the valacyclovir group compared to the acyclovir group (18% vs. 57%, p = 0.0004). Patients receiving valacyclovir prophylaxis also had less severe infection evidenced by a reduction in CMV disease, lower peak CMV titers, delayed CMV reactivation, and less secondary neutropenia. CONCLUSION Prospective evaluation of valacyclovir 1 g three times daily for viral prophylaxis following allogeneic HCT is warranted. Due to valacyclovir's favorable toxicity profile and affordable cost, it has the potential to benefit patients on a broad scale as an option for CMV prophylaxis.
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Affiliation(s)
- Kelly G Hawks
- Department of Pharmacy Services, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Amanda Fegley
- Department of Pharmacy Services, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Roy T Sabo
- Department of Biostatistics, 6889Virginia Commonwealth University, Richmond, VA, USA
| | - Catherine H Roberts
- Department of Internal Medicine, Massey Cancer Center, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Amir A Toor
- Department of Internal Medicine, Massey Cancer Center, 6887Virginia Commonwealth University Health System, Richmond, VA, USA
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The Ten Most Common Questions on Cytomegalovirus Infection in Hematopoietic Stem Cell Transplant Patients. Clin Hematol Int 2022; 5:21-28. [PMID: 36577863 PMCID: PMC9797381 DOI: 10.1007/s44228-022-00025-3] [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: 09/06/2022] [Accepted: 11/15/2022] [Indexed: 12/30/2022] Open
Abstract
With the rising number of patients undergoing hematopoietic stem cell transplantation (HSCT), clinicians are more likely to encounter infectious complications in immunocompromised hosts, particularly cytomegalovirus (CMV) infection. Besides the high mortality of CMV end-organ disease, patients with detectable CMV viremia may have worse outcomes and decreased survival even in the absence of end-organ disease. In view of the implications on morbidity and mortality, clinicians should maintain a high index of suspicion and initiate antiviral drugs promptly when CMV infection is confirmed. High-risk patients should be identified in order to provide optimal management. Additionally, novel antiviral agents with a good safety profile and minor adverse events are now available for prophylaxis in high-risk patients and for treatment of resistant or refractory CMV infection. The following review provides concise, yet comprehensive, guidance on the burden and risk factors of CMV in this population, as well as an update on the latest evidence for the management of CMV infection.
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Vyas A, Raval AD, Kamat S, LaPlante K, Tang Y, Chemaly RF. Real-World Outcomes Associated With Letermovir Use for Cytomegalovirus Primary Prophylaxis in Allogeneic Hematopoietic Cell Transplant Recipients: A Systematic Review and Meta-analysis of Observational Studies. Open Forum Infect Dis 2022; 10:ofac687. [PMID: 36726548 PMCID: PMC9879759 DOI: 10.1093/ofid/ofac687] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
Background A systematic review and meta-analysis of real-world observational studies was conducted to summarize the impact of letermovir cytomegalovirus (CMV) primary prophylaxis (PP) among adult allogeneic hematopoietic cell transplant (allo-HCT) recipients. Methods Systematic searches in Medline/PubMed, Embase, and conferences (from database inception to October 2021) were conducted to identify studies for inclusion. Random-effects models were used to derive pooled estimates on the relative effectiveness of letermovir PP compared to controls. Results Forty-eight unique studies (N = 7104 patients) were included, most of which were comparative, single-center, and conducted in the United States. Letermovir PP was associated with statistically significant reduction in odds of CMV reactivation (pooled odds ratio [pOR], 0.13 and 0.24; P < .05), clinically significant CMV infection (pOR, 0.09 and 0.19; P < .05), and CMV disease (pOR, 0.31 and 0.35; P < .05) by day +100 and day +200 after allo-HCT, respectively. Letermovir PP was associated with significantly lower odds of all-cause (pOR, 0.73; P < .01) and nonrelapse mortality (pOR, 0.65; P = .01) beyond day 200 after allo-HCT. Conclusions Letermovir for CMV PP was effective in reducing the risk of CMV-related complications overall and mortality beyond day 200 among adult allo-HCT recipients.
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Affiliation(s)
- Ami Vyas
- Correspondence: Ami Vyas, PhD, MS, MBA, Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, 7 Greenhouse Road, Kingston, RI 02881, USA ()
| | - Amit D Raval
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Rahway, New Jersey, USA
| | - Shweta Kamat
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Kerry LaPlante
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Yuexin Tang
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Rahway, New Jersey, USA
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Ranti J, Perkonoja K, Kauko T, Korhonen R. Clinical and healthcare burden of disease associated with cytomegalovirus in allogeneic hematopoietic stem cell transplantation - A retrospective single-center study. Transpl Infect Dis 2022; 24:e13947. [PMID: 36082437 PMCID: PMC10369922 DOI: 10.1111/tid.13947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/21/2022] [Accepted: 08/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND CMV infection is a common complication in allogeneic hematopoietic stem cell transplantation (HSCT). We investigated the association of clinically significant CMV (CS-CMV) infection with clinical outcomes and healthcare resource utilization in allogeneic HSCT patients in Finland. METHODS This retrospective study included adult patients who received their first allogeneic HSCT between January 1, 2013, and December 31, 2018, at the Turku University Hospital. Data were collected from the hospital data lake. Clinical and healthcare outcomes were investigated at one year and mortality up to three years. RESULTS The study included 251 patients. CMV seroprevalence was 69.7%. CS-CMV infection occurred in 59.0% of the patients, and of those, 14.2% had ≥2 infections. The median time to CS-CMV infection was 34.5 days (Q1 -Q3 , 27.0-45.0). Recipient and donor seropositivity, and lymphoproliferative diseases were associated with higher, and HLA identical sibling donors with lower CS-CMV infection risk. CS-CMV infection was not associated with mortality in three years of follow-up. One hundred thirty-three (89.8%) and 75 (72.8%) patients with and without CS-CMV infection, respectively, were readmitted to the hospital. Patients with CS-CMV infection had more hospital readmissions (incidence rate ratio [IRR] 1.38, 95% confidence interval [CI] 1.10-1.73, p = .005) and patients with one CS-CMV infection (IRR 1.48, 95% CI 1.12-1.94, p = .005) or ≥2 infections had longer length of hospital stay (IRR 2.71, 95% CI 1.76-4.35, p < .001). CONCLUSION CMV seroprevalence is relatively high among Finnish allogeneic HSCT patients. CS-CMV infection was common and associated with a higher readmission rate and longer length of hospital stay.
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Affiliation(s)
- Juha Ranti
- Department of Hematology, Turku University Hospital, Hospital District of Southwest Finland, Turku, Finland
| | - Katariina Perkonoja
- Auria Clinical Informatics, Hospital District of Southwest Finland, Turku, Finland
| | - Tommi Kauko
- Auria Clinical Informatics, Hospital District of Southwest Finland, Turku, Finland
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Liu G, Chen H, Cao X, Jia L, Rui W, Zheng H, Huang D, Liu F, Liu Y, Zhao X, Lu P, Lin X. Efficacy of pp65-specific TCR-T cell therapy in treating cytomegalovirus infection after hematopoietic stem cell transplantation. Am J Hematol 2022; 97:1453-1463. [PMID: 36054234 DOI: 10.1002/ajh.26708] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/15/2022] [Accepted: 08/21/2022] [Indexed: 01/28/2023]
Abstract
Cytomegalovirus (CMV) infection remains a major cause of mortality after hematopoietic stem cell transplantation (HSCT). Current treatments, including antiviral drugs and adoptive cell therapy with CMV-specific cytotoxic T lymphocytes (CTLs), only show limited benefits in patients. T-cell receptor (TCR)-T cell therapy offers a promising option to treat CMV infections. Here, using tetramer-based screening and single-cell TCR cloning technologies, we identified various CMV antigen-specific TCRs from healthy donors, and generated TCR-T cells targeting multiple pp65 epitopes corresponding to three major HLA-A alleles. The TCR-T cells showed efficient cytotoxicity toward epitope-expressing target cells in vitro. After transfer into immune-deficient mice bearing pp65+ HLA+ tumor cells, TCR-T cells induced dramatic tumor regression and exhibited long-term persistence. In a phase I clinical trial (NCT04153279), CMV TCR-T cells were applied to treat patients with CMV reactivation after HSCT. Except one patient who withdrew at early treatment stage, all other six patients were well-tolerated and achieved complete response (CR), no more than grade 2 cytokine release syndrome (CRS) and other adverse events were observed. CMV TCR-T cells persisted up to 3 months. Among them, two patients have survived for more than 1 year. This study demonstrates the great potential in the treatment and prevention of CMV infection following HSCT or other organ transplantation.
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Affiliation(s)
- Guangna Liu
- Department of Basic Medical Sciences and Institute for Immunology, Tsinghua University School of Medicine, Beijing, China.,School of Biomedical Sciences, Hunan University, Changsha, China
| | - Hua Chen
- Department of Basic Medical Sciences and Institute for Immunology, Tsinghua University School of Medicine, Beijing, China.,BriStar Immunotech Co, Beijing, China
| | - Xingyu Cao
- Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Lemei Jia
- School of Life Sciences, Tsinghua University, Beijing, China
| | - Wei Rui
- BriStar Immunotech Co, Beijing, China
| | | | - Daosheng Huang
- Department of Basic Medical Sciences and Institute for Immunology, Tsinghua University School of Medicine, Beijing, China
| | - Fang Liu
- BriStar Immunotech Co, Beijing, China
| | - Yue Liu
- School of Life Sciences, Tsinghua University, Beijing, China
| | - Xueqiang Zhao
- Department of Basic Medical Sciences and Institute for Immunology, Tsinghua University School of Medicine, Beijing, China.,BriStar Immunotech Co, Beijing, China
| | - Peihua Lu
- Hebei Yanda Lu Daopei Hospital, Langfang, China
| | - Xin Lin
- Department of Basic Medical Sciences and Institute for Immunology, Tsinghua University School of Medicine, Beijing, China
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41
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Cui J, Zhao K, Sun Y, Wen R, Zhang X, Li X, Long B. Diagnosis and treatment for the early stage of cytomegalovirus infection during hematopoietic stem cell transplantation. Front Immunol 2022; 13:971156. [PMID: 36211358 PMCID: PMC9537469 DOI: 10.3389/fimmu.2022.971156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Cytomegalovirus (CMV) infection remains a frequent complication after hematopoietic stem cell transplantation (HSCT) and causes significant morbidity and mortality in transplantation recipients. In this review, we highlight the role of major risk factors that are associated with the incidence of CMV infection. Advances in immunosurveillance may predict CMV infection, allowing early interventions to prevent severe infection. Furthermore, numerous therapeutic strategies against CMV infection after HSCT are summarized. A comprehensive understanding of the current situation of CMV treatment may provide a hint for clinical practice and even promote the development of novel strategies for precision medicine.
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Affiliation(s)
| | | | | | | | | | - Xudong Li
- *Correspondence: Bing Long, longb3@ mail.sysu.edu.cn; Xudong Li,
| | - Bing Long
- *Correspondence: Bing Long, longb3@ mail.sysu.edu.cn; Xudong Li,
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Xia J, Li X, Gui G, Wu J, Gong S, Shang Y, Fan J. Early immune surveillance to predict cytomegalovirus outcomes after allogeneic hematopoietic stem cell transplantation. Front Cell Infect Microbiol 2022; 12:954420. [PMID: 35992173 PMCID: PMC9382130 DOI: 10.3389/fcimb.2022.954420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThere is no method of predicting human cytomegalovirus (HCMV) outcomes in allogeneic hematopoietic stem cell transplant recipients clinically, leading in some cases to excessive or insufficient antiviral therapy. We evaluated the early immune response of recipients with disparate HCMV outcomes.MethodsThe HCMV outcomes of recipients were determined by long-term monitoring of HCMV DNA levels posttransplant. HCMV IgG and IgM concentrations at 1 week before and 1 week after transplantation, absolute lymphocyte counts, and HCMV-specific IFN-γ secreting cells at 1 month posttransplant were evaluated based on HCMV outcome.ResultsAll recipients were negative for HCMV IgM. Significant differences between recipients with and without HCMV reactivation were observed in pre- and post-transplant HCMV IgG antibody levels, absolute lymphocyte counts, and HCMV-specific IFN-γ secreting cells (P < 0.05). HCMV IgG antibody levels significantly increased after transplantation in recipients with HCMV reactivation (P = 0.032), but not in those without reactivation. Multivariate analysis revealed that except for the absolute lymphocyte count these biomarkers were related to HCMV reactivation, independent of other clinical factors. In time-to-event analyses, lower levels of these biomarkers were associated with an increased 150-day cumulative incidence of HCMV reactivation (log-rank P < 0.05). In recipients with HCMV reactivation, the duration of HCMV DNAemia had negative correlation with HCMV-specific IFN-γ-secreting cells (P = 0.015, r = -0.372). The relationships between the peak HCMV DNA load and absolute lymphocyte count and HCMV-specific IFN-γ-secreting cells followed the same trends (P = 0.026, r = -0.181 and P = 0.010, r = -0.317).ConclusionsHCMV IgG, absolute lymphocyte count, and HCMV-specific IFN-γ secreting cells represent the humoral and cellular immune response. Early monitoring of these immune markers could enable prediction of HCMV outcomes posttransplant and assessment of the severity of HCMV DNAemia.
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Affiliation(s)
- Jintao Xia
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xuejie Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Genyong Gui
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shengnan Gong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuxin Shang
- Department of Life Sciences, Faculty of Natural Sciences, Imperial College London South Kensington Campus, London, United Kingdom
| | - Jun Fan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- *Correspondence: Jun Fan,
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P Daukshus N, Cirincione A, Siver M, Mathew S, Kunvarjee B, Chan A, Boelens JJ, Seo SK, Papanicolaou GA, Kernan NA. Letermovir for Cytomegalovirus Prevention in Adolescent Patients Following Hematopoietic Cell Transplantation. J Pediatric Infect Dis Soc 2022; 11:337-340. [PMID: 35472147 PMCID: PMC9989834 DOI: 10.1093/jpids/piac017] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/07/2022] [Indexed: 01/07/2023]
Abstract
There are limited data for letermovir as primary cytomegalovirus (CMV) prophylaxis in patients less than 18 years of age. We report 9 adolescent patients who received letermovir following hematopoietic cell transplantation. No patients developed clinically significant CMV while taking letermovir. Letermovir was well tolerated and efficacious in preventing CMV infections.
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Affiliation(s)
- Nicole P Daukshus
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Molly Siver
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Sherry Mathew
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Binni Kunvarjee
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amelia Chan
- Department of Pharmacy, 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
| | - Susan K Seo
- Infectious Disease Service, 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
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Immunoprofiling reveals cell subsets associated with the trajectory of cytomegalovirus reactivation post stem cell transplantation. Nat Commun 2022; 13:2603. [PMID: 35546552 PMCID: PMC9095831 DOI: 10.1038/s41467-022-29943-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/15/2022] [Indexed: 11/11/2022] Open
Abstract
Human cytomegalovirus reactivation is a major opportunistic infection after allogeneic haematopoietic stem cell transplantation and has a complex relationship with post-transplant immune reconstitution. Here, we use mass cytometry to define patterns of innate and adaptive immune cell reconstitution at key phases of human cytomegalovirus reactivation in the first 100 days post haematopoietic stem cell transplantation. Human cytomegalovirus reactivation is associated with the development of activated, memory T-cell profiles, with faster effector-memory CD4+ T-cell recovery in patients with low-level versus high-level human cytomegalovirus DNAemia. Mucosal-associated invariant T cell levels at the initial detection of human cytomegalovirus DNAemia are significantly lower in patients who subsequently develop high-level versus low-level human cytomegalovirus reactivation. Our data describe distinct immune signatures that emerged with human cytomegalovirus reactivation after haematopoietic stem cell transplantation, and highlight Mucosal-associated invariant T cell levels at the first detection of reactivation as a marker that may be useful to anticipate the magnitude of human cytomegalovirus DNAemia. Human cytomegalovirus is a major cause of morbidity and mortality in transplant patients and multiple immune cells types are critical during infection and reactivation. Here the authors assess the immune cell compartments of haematopoietic stem cell recipients in the early period post transplantation and identify key features of effector memory CD4+ T cells and mucosal associated invariant T cells in this context.
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An eIF3d-dependent switch regulates HCMV replication by remodeling the infected cell translation landscape to mimic chronic ER stress. Cell Rep 2022; 39:110767. [PMID: 35508137 PMCID: PMC9127984 DOI: 10.1016/j.celrep.2022.110767] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/07/2022] [Accepted: 04/11/2022] [Indexed: 11/20/2022] Open
Abstract
Regulated loading of eIF3-bound 40S ribosomes on capped mRNA is generally dependent upon the translation initiation factor eIF4E; however, mRNA translation often proceeds during physiological stress, such as virus infection, when eIF4E availability and activity are limiting. It remains poorly understood how translation of virus and host mRNAs are regulated during infection stress. While initially sensitive to mTOR inhibition, which limits eIF4E-dependent translation, we show that protein synthesis in human cytomegalovirus (HCMV)-infected cells unexpectedly becomes progressively reliant upon eIF3d. Targeting eIF3d selectively inhibits HCMV replication, reduces polyribosome abundance, and interferes with expression of essential virus genes and a host gene expression signature indicative of chronic ER stress that fosters HCMV reproduction. This reveals a strategy whereby cellular eIF3d-dependent protein production is hijacked to exploit virus-induced ER stress. Moreover, it establishes how switching between eIF4E and eIF3d-responsive cap-dependent translation can differentially tune virus and host gene expression in infected cells. Instead of eIF4E-regulated ribosome loading, Thompson et al. show capped mRNA translation in HCMV-infected cells becomes reliant upon eIF3d. Depleting eIF3d inhibits HCMV replication, reduces polyribosomes, and restricts virus late gene and host chronic ER stress-induced gene expression. Thus, switching to eIF3d-responsive translation tunes gene expression to support virus replication.
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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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Shen MZ, Hong SD, Wang J, Zhang XH, Xu LP, Wang Y, Yan CH, Chen H, Chen YH, Han W, Wang FR, Wang JZ, Liu KY, Huang XJ, Mo XD. A Predicted Model for Refractory/Recurrent Cytomegalovirus Infection in Acute Leukemia Patients After Haploidentical Hematopoietic Stem Cell Transplantation. Front Cell Infect Microbiol 2022; 12:862526. [PMID: 35392613 PMCID: PMC8981086 DOI: 10.3389/fcimb.2022.862526] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Objective We aimed to establish a model that can predict refractory/recurrent cytomegalovirus (CMV) infection after haploidentical donor (HID) hematopoietic stem cell transplantation (HSCT). Methods Consecutive acute leukemia patients receiving HID HSCT were enrolled (n = 289). We randomly selected 60% of the entire population (n = 170) as the training cohort, and the remaining 40% comprised the validation cohort (n = 119). Patients were treated according to the protocol registered at https://clinicaltrials.gov (NCT03756675). Results The model was as follows: Y = 0.0322 × (age) - 0.0696 × (gender) + 0.5492 × (underlying disease) + 0.0963 × (the cumulative dose of prednisone during pre-engraftment phase) - 0.0771 × (CD34+ cell counts in graft) - 1.2926. The threshold of probability was 0.5243, which helped to separate patients into high- and low-risk groups. In the low- and high-risk groups, the 100-day cumulative incidence of refractory/recurrent CMV was 42.0% [95% confidence interval (CI), 34.7%-49.4%] vs. 63.7% (95% CI, 54.8%-72.6%) (P < 0.001) for total patients and was 50.5% (95% confidence interval (CI), 40.9%-60.1%) vs. 71.0% (95% CI, 59.5%-82.4%) (P = 0.024) for those with acute graft-versus-host disease. It could also predict posttransplant mortality and survival. Conclusion We established a comprehensive model that could predict the refractory/recurrent CMV infection after HID HSCT. Clinical Trial Registration https://clinicaltrials.gov, identifier NCT03756675.
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Affiliation(s)
- Meng-Zhu Shen
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Shen-Da Hong
- National Institute of Health Data Science at Peking University, Peking University Health Science Center, Beijing, China
| | - Jie Wang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Department of Hematology, The Second Affiliated Hospital of Shandong First Medical University, Shandong, China
| | - Xiao-Hui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Lan-Ping Xu
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu Wang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Chen-Hua Yan
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Huan Chen
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Wei Han
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Feng-Rong Wang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Jing-Zhi Wang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Kai-Yan Liu
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Dong Mo
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, China
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Zhang Y, Liang Y, Zhang X, Wang S, Cao J, Gao Z, Li L, Mo W. Pre-Transplant Platelet Refractoriness and Alternative Donors Are Associated With Cytomegalovirus Retinitis in Hematopoietic Stem Cell Transplantation for Severe Aplastic Anemia. Front Cell Infect Microbiol 2022; 12:870296. [PMID: 35372094 PMCID: PMC8964998 DOI: 10.3389/fcimb.2022.870296] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/23/2022] [Indexed: 01/17/2023] Open
Abstract
Background Cytomegalovirus retinitis is a severe, vision-threatening opportunistic infection in an immunodeficient population. Reports on cytomegalovirus retinitis in hematopoietic stem cell transplant recipients due to severe aplastic anemia have been scant. This study assessed the risk of cytomegalovirus retinitis in relation to the pre-transplant status of severe aplastic anemia patients. Methods We conducted a retrospective nested case-control study of cytomegalovirus retinitis among severe aplastic anemia patients receiving allogeneic hematopoietic stem cell transplants in a tertiary care institution that attends severe aplastic anemia patients from southern China from January 1, 2013 to December 31, 2018. Each cytomegalovirus retinitis case was matched with four controls without cytomegalovirus retinitis by age and gender. Thirteen pre-transplant parameters were chosen to compare the risk factor levels between the cases and controls. Multivariable logistic regressions were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). Results A total of 361 severe aplastic anemia patients received hematopoietic stem cell transplants in the study period 2013–2018 in our medical institution, and 31 (8.58%) developed cytomegalovirus retinitis. Cytomegalovirus retinitis was diagnosed in the median of 148 days after transplantation. We confirmed platelet refractoriness more frequently in cases than in controls (p = 0.0005). Compared with human leukocyte antigen-matched sibling donors, alternative donors were significantly more prone to cytomegalovirus retinitis (p = 0.0009). After stepwise selection in multivariate logistic regression, platelet refractoriness (OR 5.41, 95% CI 1.98–15.39), haploidentical donor (OR 7.46, 95% CI 2.19–34.87), and unrelated donor (OR 8.38, 95% CI 2.30–41.34) were associated with an increased risk of cytomegalovirus retinitis. Conclusions Pre-transplant platelet refractoriness and alternative donors were significant predictors of cytomegalovirus retinitis in severe aplastic anemia recipients. These results highlight the importance of accounting for existing risks while developing prevention strategies and preemptive treatment for severe aplastic anemia recipients. We recommend that the platelet count be closely monitored and thrombopoietin be properly applied during the period when cytomegalovirus retinitis is prone to occur.
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Affiliation(s)
- Yuehong Zhang
- Department of Ophthalmology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Yuqin Liang
- Department of Ophthalmology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Xu Zhang
- Department of Ophthalmology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jinpeng Cao
- State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
- Guangzhou Laboratory, Bio-Island, Guangzhou, China
| | - Zongyin Gao
- Department of Ophthalmology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Ling Li
- Department of Biology, University of North Dakota, Grand Forks, ND, United States
- *Correspondence: Wenjian Mo, ; Ling Li,
| | - Wenjian Mo
- Department of Hematology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
- *Correspondence: Wenjian Mo, ; Ling Li,
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Abstract
While many viral infections are limited and eventually resolved by the host immune response or by death of the host, other viruses establish long-term relationships with the host by way of a persistent infection, that range from chronic viruses that may be eventually cleared to those that establish life-long persistent or latent infection. Viruses infecting hosts from bacteria to humans establish quiescent infections that must be reactivated to produce progeny. For mammalian viruses, most notably herpesviruses, this quiescent maintenance of viral genomes in the absence of virus replication is referred to as latency. The latent strategy allows the virus to persist quiescently within a single host until conditions indicate a need to reactivate to reach a new host or, to re-seed a reservoir within the host. Here, I review common themes in viral strategies to regulate the latent cycle and reactivate from it ranging from bacteriophage to herpesviruses with a focus on human cytomegalovirus (HCMV). Themes central to herpesvirus latency include, epigenetic repression of viral gene expression and mechanisms to regulate host signaling and survival. Critical to the success of a latent program are mechanisms by which the virus can "sense" fluctuations in host biology (within the host) or environment (outside the host) and make appropriate "decisions" to maintain latency or re-initiate the replicative program. The signals or environments that indicate the establishment of a latent state, the very nature of the latent state, as well as the signals driving reactivation have been topics of intense study from bacteriophage to human viruses, as these questions encompass the height of complexity in virus-host interactions-where the host and the virus coexist.
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Affiliation(s)
- Felicia Goodrum
- Department of Immunobiology, BIO5 Institute, University of Arizona, Tucson, AZ, United States.
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Asari K, Ishii M, Yoshitsugu H, Wakana A, Fancourt C, Yoon E, Furihata K, McCrea JB, Stoch SA, Iwamoto M. Pharmacokinetics, Safety, and Tolerability of Letermovir Following Single- and Multiple-Dose Administration in Healthy Japanese Subjects. Clin Pharmacol Drug Dev 2022; 11:938-948. [PMID: 35238179 DOI: 10.1002/cpdd.1081] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/24/2022] [Indexed: 11/09/2022]
Abstract
Letermovir is a human cytomegalovirus terminase inhibitor for the prophylaxis of cytomegalovirus infection and disease in allogeneic hematopoietic stem cell transplant recipients. The pharmacokinetics, safety, and tolerability of letermovir were assessed in healthy Japanese subjects in 2 phase 1 trials: trial 1-single ascending oral doses (240, 480, and 720 mg) and intravenous (IV) doses (240, 480, and 960 mg), and trial 2-multiple oral doses (240 and 480 mg once daily for 7 days). Following administration of oral single and multiple doses, letermovir was absorbed with a median time to maximum plasma concentration of 2 to 4 hours, and concentrations declined in a biphasic manner with a terminal half-life of ≈10 to 13 hours. The post absorption plasma concentration-time profile of letermovir following oral administration was similar to the profile observed with IV dosing. There was minimal accumulation with multiple-dose administration. Letermovir exposure in healthy Japanese subjects was ≈1.5- to 2.5-fold higher than that observed in non-Japanese subjects. Based on the population pharmacokinetic analysis, weight differences primarily accounted for the higher exposures observed in Asians. Letermovir was generally well tolerated following oral and IV administration to healthy Japanese subjects.
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Affiliation(s)
| | | | | | | | | | - Esther Yoon
- PAREXEL International Early Phase Research Physicians, Glendale, California, USA
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