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Law N, Logan C, Taplitz R. EBV Reactivation and Disease in Allogeneic Hematopoietic Stem Cell Transplant (HSCT) Recipients and Its Impact on HSCT Outcomes. Viruses 2024; 16:1294. [PMID: 39205268 PMCID: PMC11359191 DOI: 10.3390/v16081294] [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: 06/20/2024] [Revised: 08/02/2024] [Accepted: 08/10/2024] [Indexed: 09/04/2024] Open
Abstract
The acquisition or reactivation of Epstein-Barr virus (EBV) after allogeneic Hematopoietic Stem Cell Transplant (HSCT) can be associated with complications including the development of post-transplant lymphoproliferative disorder (PTLD), which is associated with significant morbidity and mortality. A number of risk factors for PTLD have been defined, including T-cell depletion, and approaches to monitoring EBV, especially in high-risk patients, with the use of preemptive therapy upon viral activation have been described. Newer therapies for the preemption or treatment of PTLD, such as EBV-specific cytotoxic T-cells, hold promise. Further studies to help define risks, diagnosis, and treatment of EBV-related complications are needed in this at-risk population.
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Affiliation(s)
- Nancy Law
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, La Jolla, CA 92093, USA
| | - Cathy Logan
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, La Jolla, CA 92093, USA
| | - Randy Taplitz
- Division of Infectious Diseases, Department of Medicine, City of Hope National Medical Center, Duarte, CA 91010, USA;
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Marjańska A, Pogorzała M, Dziedzic M, Czyżewski K, Richert-Przygońska M, Dębski R, Bogiel T, Styczyński J. Impact of prophylaxis with rituximab on EBV-related complications after allogeneic hematopoietic cell transplantation in children. Front Immunol 2024; 15:1427637. [PMID: 39055711 PMCID: PMC11269116 DOI: 10.3389/fimmu.2024.1427637] [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: 05/04/2024] [Accepted: 06/28/2024] [Indexed: 07/27/2024] Open
Abstract
Background Children undergoing allo-HCT are at high risk of EBV-related complications. The objective of the study was to analyze the impact of prophylactic post-transplant rituximab on EBV infection and EBV-PTLD in children after allo-HCT, to determine the risk factors for the development of EBV infection and EBV-PTLD and to determine their outcomes. Additionally, the impact of EBV-driven complications on transplant outcomes was analyzed. Methods Single center retrospective analysis of EBV-related complications in pediatric population undergoing allo-HCT, based on strategy of prophylaxis with rituximab. Overall 276 consecutive children, including 122 on prophylaxis, were analyzed for EBV-driven complications and transplant outcomes. Results Prophylaxis with rituximab resulted in significant reduction of EBV infection (from 35.1% to 20.5%; HR=2.7; p<0.0001), and EBV-PTLD (from 13.0% to 3.3%; HR=0.23; p=0.0045). A trend for improved survival was also observed (HR=0.66; p=0.068), while non-relapse mortality was comparable in both cohorts. The peak value of viral load was a risk factor in the development of EBV-PTLD: 10-fold higher peak viral load in comparison to the baseline 104 copies/mL, caused a 3-fold (HR=3.36; p<0.001) increase in the risk of EBV-PTLD. Rituximab treatment was effective as a preemptive therapy in 91.1%, and in 70.9% in EBV-PTLD. Patients who developed PTLD had dismal 5-year overall survival (29% vs 60%; p<0.001), and an increased risk of relapse (72% vs 35%; p=0.024). Conclusions Rituximab for prophylaxis of EBV infection and EBV-PTLD was highly effective in pediatric population. Treatment of EBV-PTLD was successful in 70%, however the occurrence of EBV-PTLD was associated with an increased risk of relapse of primary malignant disease.
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Affiliation(s)
- Agata Marjańska
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University Torun, Collegium Medicum, Bydgoszcz, Poland
| | - Monika Pogorzała
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University Torun, Collegium Medicum, Bydgoszcz, Poland
| | - Magdalena Dziedzic
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University Torun, Collegium Medicum, Bydgoszcz, Poland
| | - Krzysztof Czyżewski
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University Torun, Collegium Medicum, Bydgoszcz, Poland
| | - Monika Richert-Przygońska
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University Torun, Collegium Medicum, Bydgoszcz, Poland
| | - Robert Dębski
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University Torun, Collegium Medicum, Bydgoszcz, Poland
| | - Tomasz Bogiel
- Department of Microbiology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
| | - Jan Styczyński
- Department of Pediatric Hematology and Oncology, Nicolaus Copernicus University Torun, Collegium Medicum, Bydgoszcz, Poland
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Styczynski J, Tridello G, Wendel L, Knelange N, Cesaro S, Gil L, Ljungman P, Mikulska M, Averbuch D, de la Camara R. Prevalence, management, and new treatment modalities of EBV-DNA-emia and EBV-PTLD after allo-HCT: survey of Infectious Diseases Working Party EBMT. Bone Marrow Transplant 2024; 59:59-65. [PMID: 37872300 DOI: 10.1038/s41409-023-02129-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/28/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
The aim of this study was to determine the current approach of EBV-driven post-transplant complications in context of monitoring, diagnosis, prevalence and treatment in EBMT transplant centers. Routine serology testing in patient and donor before HCT is performed in 95.5% centers. Pretransplant EBV-DNA is routinely tested in all patients in 32.7% centers. Monitoring for EBV infection is feasible in 98.2% centers: including 66.7% centers using standardized PCR. Post-HCT regular monitoring is performed in all patients in 80.5% centers. Anti-EBV prophylaxis with rituximab is used in 12.4% centers. Frequency of csEBV-DNA-emia was 7.4% (adults: 6.2%, children: 12.6%). The PCR threshold used to start preemptive treatment was differentiated among centers. Frequency of EBV-PTLD was 1.6% (adults: 1.3%; children: 3.5%). First-line therapy of EBV-driven complications was rituximab and reduction of immunosuppressive therapy. The rate of failure of first-line preemptive treatment was 12.0%. EBV-specific viral-specific T-lymphocytes were available in 46.0% centers. A number of new experimental therapies were given in 28 patients with resistant/refractory PTLD. In conclusion, the prevalence of EBV-DNA-emia and EBV-PTLD over the period 2020-2021 decreased in comparison to historical data. New trends (routine pretransplant screening for EBV-DNA, wider access to VST, new experimental therapies) are being observed in management of EBV infection after allo-HCT.
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Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum Nicolaus Copernicus University Torun, Bydgoszcz, Poland.
| | | | - Lotus Wendel
- EBMT, Leiden Study Unit, Leiden, The Netherlands
| | | | - Simone Cesaro
- Pediatric Hematology Oncology, Department of the Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Lidia Gil
- University of Medical Sciences, Poznan, Poland
| | - Per Ljungman
- Karolinska University Hospital, Karolinska Comprehensive Cancer Center, and Karolinska Institutet, Stockholm, Sweden
| | - Malgorzata Mikulska
- Division of Infectious Diseases, University of Genoa and Ospedale Policlinico San Martino, Genova, Italy
| | - Dina Averbuch
- Faculty of Medicine, Hebrew University of Jerusalem, Hadassah Medical Center, Jerusalem, Israel
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Marjanska A, Styczynski J. Who is the patient at risk for EBV reactivation and disease: expert opinion focused on post-transplant lymphoproliferative disorders following hematopoietic stem cell transplantation. Expert Opin Biol Ther 2023:1-14. [PMID: 36971380 DOI: 10.1080/14712598.2023.2196366] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Post-transplant lymphoproliferative disorders (PTLD) represent a diverse group of diseases. They develop as a consequence of uncontrolled proliferation of lymphoid or plasmacytic cells resulting from T-cell immunosuppression after transplantation of either hematopoietic cells (HCT) or solid organs (SOT), caused mainly by latent Epstein-Barr virus (EBV). The risk for EBV recurrence is dependent on the level of incompetency of the immune system, presented as an impairment of T-cell immunity. AREAS COVERED This review summarizes the data on incidence and risk factors of EBV infection in patients after HCT. The median rate of EBV infection in HCT recipients was estimated at 30% after allogeneic and<1% after autologous transplant; 5% in non-transplant hematological malignancies; 30% in SOT recipients. The median rate of PTLD after HCT is estimated at 3%. The most frequently reported risk factors for EBV infection and disease include: donor EBV-seropositivity, use of T-cell depletion, especially with ATG; reduced-intensity conditioning; mismatched family or unrelated donor transplants; and acute or chronic graft-versus-host-disease. EXPERT OPINION The major risk factors for EBV infection and EBV-PTLD can be easily identified: EBV-seropositive donor, depletion of T-cells, and the use of immunosuppressive therapy. Strategies for avoiding risk factors include elimination EBV from the graft and improving T-cell function.
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Impact of donor and recipient Epstein-Barr Virus serostatus on outcomes of allogeneic hematopoietic cell transplantation: a systematic review and meta-analysis. Ann Hematol 2021; 100:763-777. [PMID: 33491135 PMCID: PMC7914248 DOI: 10.1007/s00277-021-04428-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/12/2021] [Indexed: 12/17/2022]
Abstract
Allogeneic hematopoietic cell transplant (allo-HCT) is a potentially curative therapeutic strategy that showed encouraging long-term outcomes in hematological diseases. A number of factors can influence post-transplant clinical outcomes. While Epstein-Barr virus (EBV) constitutes a trigger for development of various adverse conditions, no clinical study yet has been powered to assess the effect of EBV serostatus on the clinical outcomes in allo-HCT population. To systematically summarize and analyze the impact of donor and recipient EBV serostatus on transplant outcomes in allo-HCT recipients, meta-analyses were conducted. Selected endpoints were overall survival (OS), relapse-free survival (RFS), relapse incidence (RI), non-relapse mortality (NRM), acute graft-versus-host disease (aGVHD), chronic graft-versus-host disease (cGVHD), and de novo cGVHD. Three studies with 26,650 patients, transplanted for acute leukemias, lymphomas, chronic hematological malignancies, or non-malignant hematological diseases were included in the meta-analysis. In the whole population, with a total of 53,300 donors and recipients, the rate of EBV seropositivity was 85.1%, including 86.6% and 83.6% among transplant recipients and healthy donors, respectively. Donor EBV seropositivity increased the risk of cGVHD by 17%, de novo cGVHD by 14%, and aGHVD by 5%. Recipient EBV seropositivity increased the risk of cGVHD by 12%, de novo cGVHD by 17%; increased NRM by 11%, increased RI by 11%, decreased OS by 14%, and decreased RFS by 11%. In performed meta-analyses, donor and recipient EBV seropositivity was found to have a significant impact on transplant outcomes in patients after allo-HCT.
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Performance of advanced imaging modalities at diagnosis and treatment response evaluation of patients with post-transplant lymphoproliferative disorder: A systematic review and meta-analysis. Crit Rev Oncol Hematol 2018; 132:27-38. [DOI: 10.1016/j.critrevonc.2018.09.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/20/2018] [Accepted: 09/11/2018] [Indexed: 01/03/2023] Open
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Styczynski J. Role of PET-CT in management of posttransplant lymphoproliferative disorder. Pediatr Blood Cancer 2018; 65. [PMID: 28941029 DOI: 10.1002/pbc.26741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/10/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
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Styczynski J. Who Is the Patient at Risk of CMV Recurrence: A Review of the Current Scientific Evidence with a Focus on Hematopoietic Cell Transplantation. Infect Dis Ther 2017; 7:1-16. [PMID: 29204910 PMCID: PMC5840099 DOI: 10.1007/s40121-017-0180-z] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Indexed: 01/15/2023] Open
Abstract
Cytomegalovirus (CMV) is an agent of global infection, and its acquisition in a population is characterized by an age-dependent rise in seropositivity. After primary infection, CMV remains in the host cells in latent form, and it can reactivate in the case of immune suppression. The risk of CMV recurrence is dependent on the level of incompetency of the immune system, manifested as an impairment of T-cell immunity, including the presence and function of CMV-specific cytotoxic T lymphocytes. This article presents data on the incidence of CMV recurrence in groups of immunocompromised patients, including allogeneic hematopoietic stem cell transplantation (HSCT) patients and other groups of patients, based on a summary of reported data. The median rate of CMV recurrence in HSCT recipients was estimated as 37% after allogeneic transplant and 12% after autologous transplant, 5% in patients with nontransplant hematological malignancies, 14% in recipients of anti-CD52 therapy, 30% in solid organ transplant recipients, 21% in patients with primary immunodeficiencies, 20% during active replication in HIV-positive patients and 3.3% during antiretroviral therapy, 7% in patients with chronic kidney disease, 0.6% in patients with congenital infection, and 0.6% in neonates with primary infection. The highest risk of CMV recurrence and CMV disease is reported for HSCT CMV-seropositive recipients, regardless of donor serostatus. The odds ratio (OR) for CMV recurrence is higher for recipient-positive versus recipient-negative CMV serostatus transplants (OR 8.0), donor-negative/recipient-positive versus donor-positive/recipient-positive CMV serostatus transplants (OR 1.2), unrelated/mismatched versus matched-family donor transplants (OR 1.6), and acute graft-versus-host-disease versus other diseases (OR 3.2). Other risk factors have minor significance.
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Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland.
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