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Mancebo FJ, Nuévalos M, Lalchandani J, Martín Galiano AJ, Fernández-Ruiz M, Aguado JM, García-Ríos E, Pérez-Romero P. Cytomegalovirus UL44 protein induces a potent T-cell immune response in mice. Antiviral Res 2024; 227:105914. [PMID: 38759930 DOI: 10.1016/j.antiviral.2024.105914] [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: 02/21/2024] [Revised: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 05/19/2024]
Abstract
Due to the severity of CMV infection in immunocompromised individuals the development of a vaccine has been declared a priority. However, despite the efforts made there is no yet a vaccine available for clinical use. We designed an approach to identify new CMV antigens able to inducing a broad immune response that could be used in future vaccine formulations. We have used serum samples from 28 kidney transplant recipients, with a previously acquired CMV-specific immune response to identify viral proteins that were recognized by the antibodies present in the patient serum samples by Western blot. A band of approximately 45 kDa, identified as UL44, was detected by most serum samples. UL44 immunogenicity was tested in BALB/c mice that received three doses of the UL44-pcDNA DNA vaccine. UL44 elicited both, a strong antibody response and CMV-specific cellular response. Using bioinformatic analysis we demonstrated that UL44 is a highly conserved protein and contains epitopes that are able to activate CD8 lymphocytes of the most common HLA alleles in the world population. We constructed a UL44 ORF deletion mutant virus that produced no viral progeny, suggesting that UL44 is an essential viral protein. In addition, other authors have demonstrated that UL44 is one of the most abundant viral proteins after infection and have suggested an essential role of UL44 in viral replication. Altogether, our data suggests that UL44 is a potent antigen, and favored by its abundance, it may be a good candidate to include in a vaccine formulation.
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Affiliation(s)
- Francisco J Mancebo
- National Center for Microbiology, Instituto de Salud Carlos III. Majadahonda, Madrid, Spain
| | - Marcos Nuévalos
- National Center for Microbiology, Instituto de Salud Carlos III. Majadahonda, Madrid, Spain
| | - Jaanam Lalchandani
- National Center for Microbiology, Instituto de Salud Carlos III. Majadahonda, Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre', Instituto de Investigación Biomédica Hospital "12 de Octubre' (imas12) Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre', Instituto de Investigación Biomédica Hospital "12 de Octubre' (imas12) Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Estéfani García-Ríos
- Instituto de Agroquímica y Tecnología de Alimentos (IATA), Consejo Superior de Investigaciones Científicas (CSIC), Valencia, Spain.
| | - Pilar Pérez-Romero
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN, 46556, USA.
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2
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Fernández-Ruiz M, García-Ríos E, Redondo N, Rodríguez-Goncer I, Ruiz-Merlo T, Parra P, Sandonis V, López-Medrano F, San Juan R, González E, Polanco N, Andrés A, Navarro D, Aguado JM, Pérez-Romero P. Dynamics and Clinical Significance of Cytomegalovirus-Specific Neutralizing Antibodies in Kidney Transplant Recipients Treated with T-Cell-Depleting Agents. J Infect Dis 2024; 229:1812-1816. [PMID: 37740549 DOI: 10.1093/infdis/jiad411] [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: 05/01/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 09/24/2023] Open
Abstract
We measured cytomegalovirus (CMV)-specific antibodies that neutralize epithelial cell infection (CMV-AbNEIs) in 101 CMV-seropositive kidney transplant recipients (KTRs) at baseline and posttransplant months 3 and 6. All the patients received antithymocyte globulin and 3-month valganciclovir prophylaxis. There were no significant differences in pretransplant AbNEIs titers between KTRs that developed or did not develop any-level CMV infection or the composite of high-level infection and/or disease. One-year CMV infection-free survival was comparable between KTRs with or without pretransplant CMV-AbNEIs. No differences were observed by months 3 and 6. We observed no protective role for CMV-AbNEIs among CMV-seropositive KTRs undergoing T-cell-depleting induction.
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Affiliation(s)
- Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Estéfani García-Ríos
- National Center of Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
- Department of Science, Universidad Internacional de Valencia, Valencia, Spain
| | - Natalia Redondo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Tamara Ruiz-Merlo
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Patricia Parra
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Virginia Sandonis
- National Center of Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Rafael San Juan
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Esther González
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Natalia Polanco
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Amado Andrés
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
- Department of Nephrology, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - David Navarro
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Microbiology, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
- Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Sanitaria Hospital "12 de Octubre" (imas12), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Pilar Pérez-Romero
- National Center of Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
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3
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Essa S, Safar HA, Raghupathy R. Cytokine responses to major human Cytomegalovirus antigens in mouse model. Cytokine 2024; 176:156546. [PMID: 38359558 DOI: 10.1016/j.cyto.2024.156546] [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: 09/07/2023] [Revised: 01/30/2024] [Accepted: 02/09/2024] [Indexed: 02/17/2024]
Abstract
Human cytomegalovirus (CMV) continues to be a source of severe complications in immunologically immature and immunocompromised hosts. Effective CMV vaccines that help diminish CMV disease in transplant patients and avoid congenital infection are essential. Though the exact roles of defense mechanisms are unidentified, virus-specific antibodies and cytokine responses are known to be involved in controlling CMV infections. Identifying the CMV antigens that trigger these protective immune responses will help us choose the most suitable CMV-related proteins for future vaccines. CMV envelope glycoprotein B (UL55/gB), matrix proteins (UL83/pp65, UL99/pp28, UL32/pp150), and assembly protein UL80a/pp38 are known to be targets for antiviral immune responses. We immunized mice intraperitoneally with these five CMV-related proteins for their ability to induce specific antibody responses and cytokine production in a mouse model. We observed a significant CMV-antigen-specific antibody response to UL80a/pp38 and UL83/pp65 (E/C>2.0). Mice immunized with UL80a/pp38 had significantly higher concentrations of GM-CSF, IFN-γ, IL-2, IL-4, IL-5, and IL-17A (p<0.05). Mice immunized with UL83/pp65 showed significantly higher concentrations of GM-CSF, IFN-γ, IL-2 IL-4, IL-10, IL-12, IL-17A, and TNF-α. Ratios of Th1 to Th2 cytokines revealed a Th1 cytokine bias in mice immunized with UL80a/pp38, UL83/pp65, UL32/pp150, and UL55/gB. We suggest that stimulation with multiple CMV-related proteins, which include UL80a/pp38, UL83/pp65, UL32/pp150, and UL55/gB antigens, will allow both humoral and cellular immune responses to be efficiently activated, thus serving as appropriate CMV antigens for future novel vaccines and immune-based therapeutic design.
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Affiliation(s)
- Sahar Essa
- Department of Microbiology, College of Medicine, Kuwait University, Kuwait City, Kuwait.
| | - Hussain A Safar
- OMICS Research Unit, Health Science Center, Kuwait University, Kuwait City, Kuwait.
| | - Raj Raghupathy
- Department of Microbiology, College of Medicine, Kuwait University, Kuwait City, Kuwait
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4
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Otto WR, Vora SB, Dulek DE. Cytomegalovirus Cell-mediated Immunity Assays in Pediatric Transplantation. J Pediatric Infect Dis Soc 2024; 13:S22-S30. [PMID: 38417088 DOI: 10.1093/jpids/piae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/23/2024] [Indexed: 03/01/2024]
Abstract
Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in pediatric transplantation. However, currently utilized CMV prevention paradigms have limitations, leading to research aimed at novel strategies for mitigation of CMV infection. Cell-mediated immunity (CMI) is crucial in controlling CMV infection and the use of CMV-specific CMI assays to guide prevention and treatment of CMV infection in both solid organ transplant and hematopoietic cell transplant recipients shows great promise. In this article, we review the immune response to CMV infection to highlight the rationale for CMI assays, describe available commercial assays and strategies for their use, and summarize relevant literature regarding the use of CMI assays in transplant recipients.
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Affiliation(s)
- William R Otto
- Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Surabhi B Vora
- Division of Infectious Diseases, Seattle Children's Hospital, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Daniel E Dulek
- Division of Pediatric Infectious Diseases, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Pednekar P, Graf M, Tuly R, Batt K, Wang C. Gaining consensus around patient risk groups and prognostic profiles to guide CMV management among patients with solid organ transplant: Insights from a Delphi panel with SOT experts. Clin Transplant 2023; 37:e14905. [PMID: 36603193 DOI: 10.1111/ctr.14905] [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: 09/30/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 01/07/2023]
Abstract
INTRODUCTION This study aimed to characterize patient risk groups and respective prognostic profiles to optimize clinical decision-making and guide appropriate medical cytomegalovirus (CMV) management among patients with solid organ transplant (SOT). METHODS Between September 2021 and February 2022, a three-round modified Delphi study was conducted to generate consensus among 14 international experts in virology and organ transplantation. Experts were asked about treatment and prognoses for patients in seven distinct clinical scenarios. Furthermore, experts were asked to risk-stratify patients by pre-/post-transplant characteristics. Consensus around opting for/against a treatment was observed if ≥75% or <25% of experts reported ≥50% likelihood to recommend or if treatments were ranked inside/outside the top two options and ≥75% of experts were within 1 standard deviation of the mean rank. RESULTS Experts agreed on several unmet needs in CMV disease management post-SOT, particularly avoidance of treatment-limiting toxicities with conventional CMV therapy and emergence of both primary refractory and drug resistant treatment failures. Experts considered CMV viral load, resistance profile, and route of administration as critical to treatment selection. For newer CMV therapeutic options, experts listed lack of long-term use data, concerns over potential resistance, high cost and limited availability as challenges restricting adoption, and successful patient management. CONCLUSION Experts achieved consensus around patient risk stratifications and factors influencing therapeutic options. Recommendations emerging from this Delphi study may support practicing physicians when confronted with challenging CMV scenarios in SOT patients, but additional experiences with newer anti-CMV agents are needed to re-validate expert consensus and update post-transplant CMV guidelines.
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Affiliation(s)
| | | | | | | | - Connie Wang
- Hennepin Healthcare, Minneapolis, Minnesota, USA
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6
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Zaffiri L, Messinger JE, Bush EJ, Staats JS, Patel P, Palmer SM, Weinhold KJ, Snyder LD, Luftig MA. Evaluation of host cellular responses to Epstein-Barr virus (EBV) in adult lung transplant patients with EBV-associated diseases. J Med Virol 2023; 95:e28724. [PMID: 37185866 PMCID: PMC10481801 DOI: 10.1002/jmv.28724] [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: 02/20/2023] [Revised: 03/27/2023] [Accepted: 04/02/2023] [Indexed: 05/17/2023]
Abstract
Epstein-Barr virus (EBV) reactivation is commonly observed in lung transplant recipients (LTRs). However, cellular immune responses to EBV in adult LTRs have not been well described. We aimed to study CD4/CD8 ratio, EBV-specific T cells polyfunctional responses and phenotypic changes in natural killer (NK) cells in adult LTRs presenting with EBV-associated diseases. The CD4/CD8 ratio was significantly decreased in LTRs with EBV DNAemia compared with LTRs without EBV DNAemia and healthy controls (HCs). Stimulation with EBV lytic antigen BZLF1 peptide pools induced significant individual and polyfunctional responses from CD8+ CD69+ T cells. Frequencies of CD8+ CD69+ T cells expressing CD107a were significantly higher in LTRs without EBV DNAemia than in LTRs with DNAemia. Frequencies of CD8+ CD69+ T cells concurrently expressing CD107a, IFN-γ, and TNF-α were significantly greater in LTRs with and without EBV DNAemia than in HCs. Finally, BZLF1 induced significantly higher frequencies of CD8+ CD69+ T cells expressing CD107a and IFN-γ in LTRs without EBV DNAemia when compared with EBNA3B. Frequency of more differentiated CD56dim CD16pos NK cells was significantly decreased in LTRs with EBV DNAemia and PTLD compared with HCs. In conclusion, we noted the presence of significant changes in circulating cellular immune responses to EBV in adult LTRs.
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Affiliation(s)
- Lorenzo Zaffiri
- Cedars-Sinai Medical Center, Los Angeles, CA 90048
- Division of Pulmonary and Critical Care, Duke University,
Durham, NC, USA
| | - Joshua E Messinger
- Department of Molecular Genetics and Microbiology, Duke
University School of Medicine, Durham, NC, 27710
| | - Erika J Bush
- Division of Pulmonary and Critical Care, Duke University,
Durham, NC, USA
| | | | | | - Scott M Palmer
- Division of Pulmonary and Critical Care, Duke University,
Durham, NC, USA
| | | | - Laurie D Snyder
- Division of Pulmonary and Critical Care, Duke University,
Durham, NC, USA
| | - Micah A. Luftig
- Department of Molecular Genetics and Microbiology, Duke
University School of Medicine, Durham, NC, 27710
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7
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Nuévalos M, García-Ríos E, Mancebo FJ, Martín-Martín C, Pérez-Romero P. Novel monoclonal antibody-based therapies: implications for the treatment and prevention of HCMV disease. Trends Microbiol 2023; 31:480-497. [PMID: 36624009 DOI: 10.1016/j.tim.2022.12.003] [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: 05/30/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 01/09/2023]
Abstract
Human cytomegalovirus (HCMV) is an important pathogen worldwide. Although HCMV infection is often asymptomatic in immunocompetent individuals, it can cause severe or even life-threatening symptoms in immunocompromised patients. Due to limitations of antiviral treatments, it is necessary to search for new therapeutic alternatives. Recent studies have highlighted the contribution of antibodies in protecting against HCMV disease, including neutralizing and non-neutralizing antibodies. Given the immunocompromised target population, monoclonal antibodies (mAbs) may represent an alternative to the clinical management of HCMV infection. In this context, we provide a synthesis of recent data revising the literature supporting and arguing about the role of the humoral immunity in controlling HCMV infection. Additionally, we review the state of the art in the development of therapies based on mAbs.
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Affiliation(s)
- Marcos Nuévalos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, 28220 Madrid, Spain
| | - Estéfani García-Ríos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, 28220 Madrid, Spain; Department of Science, Universidad Internacional de Valencia-VIU, 46002 Valencia, Spain.
| | - Francisco J Mancebo
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, 28220 Madrid, Spain
| | - Clara Martín-Martín
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, 28220 Madrid, Spain
| | - Pilar Pérez-Romero
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, 28220 Madrid, Spain.
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8
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Neutralization Epitopes in Trimer and Pentamer Complexes Recognized by Potent Cytomegalovirus-Neutralizing Human Monoclonal Antibodies. Microbiol Spectr 2022; 10:e0139322. [PMID: 36342276 PMCID: PMC9784774 DOI: 10.1128/spectrum.01393-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Human cytomegalovirus (HCMV) infects 36% to almost 100% of adults and causes severe complications only in immunocompromised individuals. HCMV viral surface trimeric (gH/gL/gO) and pentameric (gH/gL/UL128/UL130/UL131A) complexes play important roles in HCMV infection and tropism. Here, we isolated and identified a total of four neutralizing monoclonal antibodies (MAbs) derived from HCMV-seropositive blood donors. Based on their reactivity to HCMV trimer and pentamer, these MAbs can be divided into two groups. MAbs PC0012, PC0014, and PC0035 in group 1 bind both trimer and pentamer and neutralize CMV by interfering with the postattachment steps of CMV entering into cells. These three antibodies recognize antigenic epitopes clustered in a similar area, which are overlapped by the epitope recognized by the known neutralizing antibody MSL-109. MAb PC0034 in group 2 binds only to pentamer and neutralizes CMV by blocking the binding of pentamer to cells. Epitope mapping using pentamer mutants showed that amino acid T94 of the subunit UL128 and K27 of UL131A on the pentamer are key epitope-associated residues recognized by PC0034. This study provides new evidence and insight information on the importance of the development of the CMV pentamer as a CMV vaccine. In addition, these newly identified potent CMV MAbs can be attractive candidates for development as antibody therapeutics for the prevention and treatment of HCMV infection. IMPORTANCE The majority of the global population is infected with HCMV, but severe complications occur only in immunocompromised individuals. In addition, CMV infection is a major cause of birth defects in newborns. Currently, there are still no approved prophylactic vaccines or therapeutic monoclonal antibodies (MAbs) for clinical use against HCMV infection. This study identified and characterized a panel of four neutralizing MAbs targeting the HCMV pentamer complex with specific aims to identify a key protein(s) and antigenic epitopes in the HCMV pentamer complex. The study also explored the mechanism by which these newly identified antibodies neutralize HCMV in order to design better HCMV vaccines focusing on the pentamer and to provide attractive candidates for the development of effective cocktail therapeutics for the prevention and treatment of HCMV infection.
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9
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Harnois MJ, Dennis M, Stöhr D, Valencia SM, Rodgers N, Semmes EC, Webster HS, Jenks JA, Barfield R, Pollara J, Chan C, Sinzger C, Permar SR. Characterization of Plasma Immunoglobulin G Responses in Elite Neutralizers of Human Cytomegalovirus. J Infect Dis 2022; 226:1667-1677. [PMID: 35970817 PMCID: PMC10205896 DOI: 10.1093/infdis/jiac341] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/11/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Human cytomegalovirus (HCMV) is the most common infectious complication of organ transplantation and cause of birth defects worldwide. There are limited therapeutic options and no licensed vaccine to prevent HCMV infection or disease. To inform development of HCMV antibody-based interventions, a previous study identified individuals with potent and broad plasma HCMV-neutralizing activity, termed elite neutralizers (ENs), from a cohort of HCMV-seropositive (SP) blood donors. However, the specificities and functions of plasma antibodies associated with EN status remained undefined. METHODS We sought to determine the plasma antibody specificities, breadth, and Fc-mediated antibody effector functions associated with the most potent HCMV-neutralizing responses in plasma from ENs (n = 25) relative to that from SP donors (n = 19). We measured antibody binding against various HCMV strains and glycoprotein targets and evaluated Fc-mediated effector functions, antibody-dependent cellular cytotoxicity (ADCC), and antibody-dependent cellular phagocytosis (ADCP). RESULTS We demonstrate that ENs have elevated immunoglobulin G binding responses against multiple viral glycoproteins, relative to SP donors. Our study also revealed potent HCMV-specific antibody-dependent cellular cytotoxicity and antibody-dependent cellular phagocytosis activity of plasma from ENs. CONCLUSIONS We conclude that antibody responses against multiple glycoprotein specificities may be needed to achieve potent plasma neutralization and that potently HCMV elite-neutralizing plasma antibodies can also mediate polyfunctional responses.
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Affiliation(s)
- Melissa J Harnois
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Immunology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Maria Dennis
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Dagmar Stöhr
- Institute for Virology, Ulm University Medical Center, Ulm, Baden-Württemberg, Germany
| | - Sarah M Valencia
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Nicole Rodgers
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eleanor C Semmes
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Medical Scientist Training Program, Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Helen S Webster
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jennifer A Jenks
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Medical Scientist Training Program, Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Richard Barfield
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Human Systems Immunology, Duke University Medical Center, Durham, North Carolina, USA
| | - Justin Pollara
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cliburn Chan
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
- Center for Human Systems Immunology, Duke University Medical Center, Durham, North Carolina, USA
| | - Christian Sinzger
- Institute for Virology, Ulm University Medical Center, Ulm, Baden-Württemberg, Germany
| | - Sallie R Permar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA
- Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
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10
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Lee H, Oh EJ. Laboratory diagnostic testing for cytomegalovirus infection in solid organ transplant patients. KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:15-28. [PMID: 35769434 PMCID: PMC9235525 DOI: 10.4285/kjt.22.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/12/2022] [Accepted: 02/15/2022] [Indexed: 11/12/2022] Open
Abstract
Human cytomegalovirus (CMV) infection, which is one of the most common complications in transplant recipients, increases the risk of graft loss and rejection. Laboratory strategies for diagnosing CMV infection rely on the measurement of viral DNAemia and CMV-specific cell-mediated immunity (CMV-CMI). The CMV quantitative nucleic acid amplification test (QNAT) enabled the spread of preemptive therapy and prompted recommendations for surveillance, diagnosis, and monitoring. Despite the implementation of the World Health Organization international standard for calibration, variability of QNAT persists due to technical issues. CMV immunoglobulin G serology is the standard method for CMV immune screening of transplant candidates and donors. Assays for CMV-CMI play an important role in helping to predict the risk and to develop an individualized CMV management plan. Genotypic testing for resistance is needed when drug-resistant CMV infection is suspected. Here, we review the state of the art of laboratory tests for CMV infection in solid organ transplantation.
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Affiliation(s)
- Hyeyoung Lee
- Department of Laboratory Medicine, International St. Mary’s Hospital, College of Medicine, Catholic Kwandong University, Incheon, Korea
| | - Eun-Jee Oh
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Research and Development Institute for In Vitro Diagnostic Medical Devices of Catholic University of Korea, College of Medicine, The Catholic University of Korea, Seoul, Korea
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11
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Suàrez-Fernández P, Utrero-Rico A, Sandonis V, García-Ríos E, Arroyo-Sánchez D, Fernández-Ruiz M, Andrés A, Polanco N, González-Cuadrado C, Almendro-Vázquez P, Pérez-Romero P, Aguado JM, Paz-Artal E, Laguna-Goya R. Circulatory follicular helper T lymphocytes associate with lower incidence of CMV infection in kidney transplant recipients. Am J Transplant 2021; 21:3946-3957. [PMID: 34153157 DOI: 10.1111/ajt.16725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 01/25/2023]
Abstract
Primary infection and/or reactivation of cytomegalovirus (CMV) in kidney transplant recipients (KTR) favor rejection and mortality. T follicular helper cells (TFH) could contribute to protection against CMV. Circulatory TFH (cTFH) were studied pretransplant and early posttransplant in 90 CMV seropositive KTR not receiving antithymocyte globulin or antiviral prophylaxis, followed-up for 1 year. Patients who presented CMV infection had significantly lower cTFH and activated cTFH pretransplant and early posttransplant. Pretransplant activated cTFH were also lower within patients who developed CMV disease. Pre- and 14 days posttransplant activated cTFH were an independent protective factor for CMV infection (HR 0.41, p = .01; and 0.52, p = .02, respectively). KTR with low cTFH 7 days posttransplant (<11.9%) had lower CMV infection-free survival than patients with high cTFH (28.2% vs. 67.6%, p = .002). cTFH were associated with CMV-specific neutralizing antibodies (Nabs). In addition, IL-21 increased interferon-γ secretion by CMV-specific CD8+ T cells in healthy controls. Thus, we show an association between cTFH and lower incidence of CMV infection, probably through their cooperation in CMV-specific Nab production and IL-21-mediated enhancement of CD8+ T cell activity. Moreover, monitoring cTFH pre- and early posttransplant could improve CMV risk stratification and help select KTR catalogued at low/intermediate risk who could benefit from prophylaxis.
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Affiliation(s)
| | - Alberto Utrero-Rico
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Virginia Sandonis
- National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Majadahonda, Spain
| | - Estéfani García-Ríos
- National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Majadahonda, Spain
| | - Daniel Arroyo-Sánchez
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mario Fernández-Ruiz
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Amado Andrés
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | - Pilar Pérez-Romero
- National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Majadahonda, Spain
| | - José María Aguado
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Estela Paz-Artal
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Rocío Laguna-Goya
- Instituto de Investigación Biomédica Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Hospital Universitario 12 de Octubre, Madrid, Spain
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12
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Carvalho-Gomes Â, Cubells A, Pallarés C, Corpas-Burgos F, Berenguer M, Aguilera V, López-Labrador FX. Cytomegalovirus specific polyfunctional T-cell responses expressing CD107a predict control of CMV infection after liver transplantation. Cell Immunol 2021; 371:104455. [PMID: 34864514 DOI: 10.1016/j.cellimm.2021.104455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/16/2021] [Accepted: 11/04/2021] [Indexed: 11/03/2022]
Abstract
Cytomegalovirus (CMV) viral load after liver transplantation (LT) is controlled by cell mediated immune responses (CMI). Quantification of CMV-specific T-cells may identify patients who control CMV spontaneously and avoid expensive and potentially toxic antiviral therapies. Prospective post-LT clinical, virological and immunological monitoring was carried out up to 1-year post-LT in a cohort of adult recipients. The CMV-specific T-cell response was characterized using flow cytometry intracellular cytokine staining in 49 LT recipients-R (79.6% R+, 20.4% R-). CMV infection occurred in 24 patients (18 D+/R+ and 6 D+/R-). Only patients with undetectable polyfunctional CMV-specific CD4+ T-cells developed CMV infection. Predictive models showed that polyfunctional CMV-specific CD4+ T-cells pre-existing before LT are protective for CMV reactivation posttransplantation. Quantitation of CD4+ T-cell responses to CMV may be a useful marker for spontaneous control of viral replication to tailor antiviral prophylaxis after LT.
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Affiliation(s)
- Ângela Carvalho-Gomes
- Liver Transplantation and Hepatology Laboratory, Hepatology, HBP Surgery and Transplant Unit, Instituto Investigación Sanitaria La Fe, Hospital U. y P. La Fe, València, Spain; CIBERehd, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Spain.
| | - Almudena Cubells
- Liver Transplantation and Hepatology Laboratory, Hepatology, HBP Surgery and Transplant Unit, Instituto Investigación Sanitaria La Fe, Hospital U. y P. La Fe, València, Spain; CIBERehd, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Spain
| | - Carmina Pallarés
- Liver Transplantation and Hepatology Laboratory, Hepatology, HBP Surgery and Transplant Unit, Instituto Investigación Sanitaria La Fe, Hospital U. y P. La Fe, València, Spain; CIBERehd, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Spain
| | - Francisca Corpas-Burgos
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO-Public Health), Av. Catalunya, 21, 46020 Valencia, Spain; CIBEResp, Instituto de Salud Carlos III, Madrid, Spain
| | - Marina Berenguer
- Liver Transplantation and Hepatology Laboratory, Hepatology, HBP Surgery and Transplant Unit, Instituto Investigación Sanitaria La Fe, Hospital U. y P. La Fe, València, Spain; CIBERehd, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Spain; Liver Transplantation and Hepatology Unit, Hospital Universitario y Politécnico La Fe, València, Spain; Department of Medicine, University of Valencia Medical School, Valencia, Spain
| | - Victoria Aguilera
- Liver Transplantation and Hepatology Laboratory, Hepatology, HBP Surgery and Transplant Unit, Instituto Investigación Sanitaria La Fe, Hospital U. y P. La Fe, València, Spain; CIBERehd, Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Spain; Liver Transplantation and Hepatology Unit, Hospital Universitario y Politécnico La Fe, València, Spain
| | - F Xavier López-Labrador
- CIBEResp, Instituto de Salud Carlos III, Madrid, Spain; Virology Laboratory, Genomics and Health Area, Centro Superior de Salud Pública, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO-Public Health), Conselleria de Sanitat, València, Spain
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13
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García-Ríos E, Nuévalos M, Mancebo FJ, Pérez-Romero P. Is It Feasible to Use CMV-Specific T-Cell Adoptive Transfer as Treatment Against Infection in SOT Recipients? Front Immunol 2021; 12:657144. [PMID: 33968058 PMCID: PMC8104120 DOI: 10.3389/fimmu.2021.657144] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/06/2021] [Indexed: 12/19/2022] Open
Abstract
During the last decade, many studies have demonstrated the role of CMV specific T-cell immune response on controlling CMV replication and dissemination. In fact, it is well established that transplanted patients lacking CMV-specific T-cell immunity have an increased occurrence of CMV replication episodes and CMV-related complications. In this context, the use of adoptive transfer of CMV-specific T-cells has been widely investigated and applied to Hematopoietic Stem Cell Transplant patients and may be useful as a therapeutic alternative, to reconstitute the CMV specific T-cell response and to control CMV viremia in patients receiving a transplantation. However, only few authors have explored the use of T-cell adoptive transfer in SOT recipients. We propose a novel review in which we provide an overview of the impact of using CMV-specific T-cell adoptive transfer on the control of CMV infection in SOT recipients, the different approaches to stimulate, isolate and expand CMV-specific T-cells developed over the years and a discussion of the possible use of CMV adoptive cellular therapy in this SOT population. Given the timeliness and importance of this topic, we believe that such an analysis will provide important insights into CMV infection and its treatment/prevention.
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Affiliation(s)
- Estéfani García-Ríos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Marcos Nuévalos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Francisco J Mancebo
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
| | - Pilar Pérez-Romero
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Spain
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14
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Sandonís V, García-Ríos E, McConnell MJ, Pérez-Romero P. Role of Neutralizing Antibodies in CMV Infection: Implications for New Therapeutic Approaches. Trends Microbiol 2020; 28:900-912. [PMID: 32448762 DOI: 10.1016/j.tim.2020.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 02/06/2023]
Abstract
Cytomegalovirus (CMV) infection elicits a potent immune response that includes the stimulation of antibodies with neutralizing activity. Recent studies have focused on elucidating the role of neutralizing antibodies in protecting against CMV infection and disease and characterizing viral antigens against which neutralizing antibodies are directed. Here, we provide a synthesis of recent data regarding the role of neutralizing antibodies in protection against CMV infection/disease. We consider the role of humoral immunity in the context of the global CMV-specific immune response, and the implications that recent findings have for vaccine and antibody-based therapy design.
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Affiliation(s)
- Virginia Sandonís
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (i+12), Madrid, Spain
| | - Estéfani García-Ríos
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Michael J McConnell
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
| | - Pilar Pérez-Romero
- National Center for Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain.
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15
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Navarro D, Fernández-Ruiz M, Aguado JM, Sandonís V, Pérez-Romero P. Going beyond serology for stratifying the risk of CMV infection in transplant recipients. Rev Med Virol 2018; 29:e2017. [PMID: 30358016 DOI: 10.1002/rmv.2017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/12/2022]
Abstract
Knowledge of donor and recipient (D/R) cytomegalovirus (CMV) serostatus is critical for risk stratification of CMV infection and disease in transplant recipients, particularly in the solid organ transplantation (SOT) setting. Despite its broad availability and the success of it use, the risk stratification based on the D/R serostatus is not free of limitations since there are a nondepreciable number of patients that are not accurately categorized by this approach. In fact, up to 20% of seropositive SOT recipients, classically considered at intermediate risk, develop episodes of CMV infection and disease after transplantation. Here, we provide an overview of additional donor and recipient factors that may have utility in identifying patients at risk for post-transplant CMV infection. Specifically, we summarize our current understanding regarding the potential use of use CMV-specific T-cell-mediated immunity, neutralizing antibodies and host genetics that may influence the risk of CMV infection and disease. We provide an overview of the benefits and limitations associated with using these immunological factors in risk stratification and propose specific variables that could be analyzed at the pretransplant evaluation to improve the identification of patients with increased individual susceptibility.
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Affiliation(s)
- David Navarro
- Microbiology Service, Hospital Clínico Universitario, Fundación INCLIVA, Valencia, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital,"12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital,"12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Virginia Sandonís
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital,"12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain
| | - Pilar Pérez-Romero
- National Center of Microbiology, Instituto de Salud Carlos III, Majadahonda, Madrid, Spain
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16
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Vietzen H, Görzer I, Honsig C, Jaksch P, Puchhammer-Stöckl E. Association between antibody functions and human cytomegalovirus (HCMV) replication after lung transplantation in HCMV-seropositive patients. J Heart Lung Transplant 2017; 37:S1053-2498(17)31901-0. [PMID: 28750933 DOI: 10.1016/j.healun.2017.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/11/2017] [Accepted: 07/11/2017] [Indexed: 01/21/2023] Open
Affiliation(s)
- Hannes Vietzen
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Irene Görzer
- Center for Virology, Medical University of Vienna, Vienna, Austria
| | - Claudia Honsig
- Division of Clinical Virology, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Division of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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17
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Mena-Romo JD, Pérez Romero P, Martín-Gandul C, Gentil MÁ, Suárez-Artacho G, Lage E, Sánchez M, Cordero E. CMV-specific T-cell immunity in solid organ transplant recipients at low risk of CMV infection. Chronology and applicability in preemptive therapy. J Infect 2017; 75:336-345. [PMID: 28599954 DOI: 10.1016/j.jinf.2017.05.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/12/2017] [Accepted: 05/30/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To characterize whether the CMV-specific cellular immune response can be used as a predictor of the control of CMV infection and disease and determine thresholds in solid organ transplant (SOT) recipients seropositive for CMV (R+). METHODS The CMV-specific T-cell response was characterized using intracellular cytokine staining and the evolution of clinical and virological parameters were recorded during the first year after transplantation. RESULTS Besides having positive CMV serology, only 28.4% patients had positive immunity (CD8+CD69+IFN-γ+ ≥0.25%) at 2 weeks after transplantation. These patients had less indication of preemptive treatment (p = 0.025) and developed less high grade (≥2000 IU/ml) CMV replication episodes (p = 0.006) than patients with no immunity. Of the 49 patients with a pretransplant sample, only 22.4% had positive immunity, and had a detectable immune response early after transplantation (median of 3.7 weeks). However, only 50% of patients with negative pretransplant immunity acquired a positive immune response and it was significantly later, at a median of 11 weeks (p < 0.001). Patients that developed CMV disease had no CMV-specific immunity. CONCLUSIONS Having CMV-specific CD8+IFN-γ+ cells ≥0.25% before transplant; 0.15% at two weeks or 0.25% at four weeks after transplantation, identifies patients that may spontaneously control CMV infection and may require less monitoring.
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Affiliation(s)
- Juan Damián Mena-Romo
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Pilar Pérez Romero
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Sevilla, Spain.
| | - Cecilia Martín-Gandul
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Sevilla, Spain
| | | | - Gonzalo Suárez-Artacho
- Hepatobiliary and Pancreatic Surgery and Hepatic Transplant Unit, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Ernesto Lage
- Service of Cardiology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Magdalena Sánchez
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Elisa Cordero
- Instituto de Biomedicina de Sevilla (IBIS)/CSIC/University of Sevilla, Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospital Virgen del Rocío, Sevilla, Spain
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