Analysis of cytomegalovirus (CMV) viremia using the pp65 antigenemia assay, the amplicor CMV test, and a semi-quantitative polymerase chain reaction test after allogeneic marrow transplantation

Update on the risk assessment of a rehabilitation stay for patients after allogeneic stem cell transplantation

OBJECTIVE

High-dose chemotherapy with allogeneic stem cell transplantation is the only chance of cure for many haemato-oncological patients. After such therapy, the immune system is weakened, and the contact with other people should therefore be limited as much as possible. The question arises whether a rehabilitation stay can be recommended to these patients, which risk factors for complications during the rehabilitation stay can be identified, and whether physicians and patients can be provided with decision-making aids as to when the optimal time is to start rehabilitation.

METHODS

We report about 161 rehabilitation stays of patients after high-dose chemotherapy with allogeneic stem cell transplantation. Premature discontinuation of the rehabilitation was selected as the criterion for a serious complication during the rehabilitation and the underlying reasons were analysed.

RESULTS

The rate of prematurely terminated rehabilitation stays (13.6%) corresponds to our previous result from 2020. The analysis of the reasons for early termination comes to the conclusion that the rehabilitation stay is only considered as a reason for termination in very few cases, if at all. The risk factors identified for premature termination of the rehabilitation stay were male sex, the period (days) between transplantation and the beginning of the rehabilitation stay, haemoglobin value, platelets and presence of immunosuppressing agent. The most significant risk factor is a decreased platelet count at the time rehabilitation begins. The platelet count, the likelihood that it will improve in the further course and the urgency of the rehabilitation stay can be used to help decide when the optimal time for rehabilitation is given.

CONCLUSION

Rehabilitation can be recommended to patients after allogeneic stem cell transplantation. Based on various factors, recommendations can be made for the right time for rehabilitation.

American Society for Transplantation and Cellular Therapy Series: #3-Prevention of Cytomegalovirus Infection and Disease After Hematopoietic Cell Transplantation

The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious diseases guidelines for the care of hematopoietic cell transplant (HCT) recipients. A new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The third topic in the series focuses on the prevention of cytomegalovirus infection and disease in HCT recipients by reviewing prophylaxis and preemptive therapy approaches; key definitions, relevant risk factors, and diagnostic monitoring considerations are also reviewed.

Does rehabilitation pose a risk to patients suffering from haemato-oncological diseases? Results of a monocentric, retrospective analysis in Germany

OBJECTIVE

Patients suffering from haemato-oncological diseases tend to have a weakened immune system after the end of their therapy. To avoid infections, patients are advised to limit contact with other people. This poses the question whether a stay at a rehabilitation facility can be recommended.

METHODS

We report about 134 rehabilitation stays of patients. Premature discontinuation of the rehabilitation stay was selected as the criterion for a serious complication during the rehabilitation, and the underlying reasons were analysed.

RESULTS

Compared to the discontinuation rates of patients suffering from solid tumours (2.4%), the percentage of haemato-oncological patients ending prematurely their rehabilitation stay (8.2%) is significantly increased. This rises to 17.1% for patients who have undergone an allogeneic stem cell transplantation. The analysis of the discontinuation reasons revealed that they were not directly connected to the rehabilitation. Apart from the already known risk factors for premature termination of the rehabilitation stay, we have identified the period (days) between the last therapy and the beginning of the rehabilitation stay as a risk factor.

CONCLUSIONS

We show for the first time that a rehabilitation stay does not pose additional risks for patients suffering from haemato-oncological diseases.

Increased mortality in hematological malignancy patients with acute respiratory failure from undetermined etiology: a Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH) study

BACKGROUND

Acute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology.

METHODS

This is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders.

RESULTS

This study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06-21.62); p < 0.005), use of invasive mechanical ventilation (OR 1.65 (95% CI 1.07-2.55); p = 0.02), a SOFA score >7 (OR 3.32 (95% CI 2.15-5.15); p < 0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71-5.07); p < 0.005).

CONCLUSIONS

In patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted. ClinicalTrials.Gov NCT01172132.

The risk factors for cytomegalovirus reactivation following stem cell transplantation

Objective:

Opportunistic infections like cytomegalovirus (CMV) are among the primary causes of morbidity and mortality in patients undergoing hematipoetic stem cell transplantation (HSCT). This infection is frequently seen in early postengraftment period. So we determined to find the risk factors associated with CMV reactivation.

Methods:

We retrospectively evaluated the medical records of 126 consecutive patients who underwent allogenic-HSCT from peripheral blood stem cells from August 2011 to February 2013 in Shariati Hospital. We included HSCT patients with 15 years of age or older, who survived at least 100 days after transplantation. CMV reactivation was detected based on the weekly PP65 assessment. Patients with 10 or more positive cells per 50,000 cells were defined as having high-level antigenemia.

Findings:

From 126 patients which included in this study, 76 were male (60%). CMV antigenemia was documented in 43 patients (34%). The median time to CMV infection was 40 days (range: 3–77) after transplantation. The incidence of high-level antigenemia during the first 100 days following HSCT was 11%.

Conclusion:

We found that the significant risk factor for CMV antigenemia in multivariate analysis was prior graft-versus-host disease (GVHD) experience and higher donor age. For high-level antigenemia, GVHD or duration of its treatment was significant determinant.

Determination of human cytomegalovirus pp65 antigenemia among renal transplant patients

Human cytomegalovirus (HCMV) is an important cause of morbidity and mortality in immunosuppressed transplant recipients. Isolation of HCMV from peripheral blood leukocytes (PBLs) is considered a reliable marker of disseminated HCMV infection. HCMV pp65 antigenemia is widely used for monitoring CMV infection and guiding preemptive therapy. The aim of this study was to compare pp65 antigenemia with culture technique for detection of HCMV in PBLs among kidney transplant patients and also to determine the threshold value of significant pp65 antigenemiat. Fifty-one peripheral blood samples from post-renal transplant patients collected during August 2009 to March 2011 were processed for pp65 antigenemia assay. These were also tested for isolation of the virus by inoculation into human corneal fibroblast cells. The results of pp65 antigenemia and culture were compared to determine the clinical significance of pp65 antigenemia. HCMV was isolated in 21 cases. On comparing the pp65 antigenemia results with that of the viral isolation, a mean of 23 cells was determined to yield a positive isolation of HCMV. The values of pp65 antigenemia and isolation results were correlated (paired t-test, P = 0.0029). A pp65 count of 23 and above was considered significant in our clinical settings since we found that these clinical specimens yield positive culture result.

Comparison of the performance of polymerase chain reaction and pp65 antigenemia for the detection of human cytomegalovirus in immunosuppressed patients

INTRODUCTION

Human cytomegalovirus (HCMV) is often reactive in latently infected immunosuppressed patients. Accordingly, HCMV remains one of the most common infections following solid organ and hemopoietic stem cell transplantations, resulting in significant morbidity, graft loss and occasional mortality. The early diagnosis of HCMV disease is important in immunosuppressed patients, since in these individuals, preemptive treatment is useful. The objective of this study was to compare the performance of the in-house qualitative polymerase chain reaction (PCR) and pp65 antigenemia to HCMV infection in immunosuppressed patients in the Hospital de Clínicas of Porto Alegre (HCPA).

METHODS

A total of 216 blood samples collected between August 2006 and January 2007 were investigated.

RESULTS

Among the samples analyzed, 81 (37.5%) were HCMV-positive by PCR, while 48 (22.2%) were positive for antigenemia. Considering antigenemia as the gold standard, sensitivity, specificity, positive predictive values and negative predictive values for PCR were 87.5%, 76.8%, 51.8% and 95.5% respectively.

CONCLUSIONS

These results demonstrated that qualitative PCR has high sensitivity and negative predictive value (NPV). Consequently PCR is especially indicated for the initial diagnosis of HCMV infection. In the case of preemptive treatment strategy, identification of patients at high-risk for HCMV disease is fundamental and PCR can be useful tool.

Monitoring human cytomegalovirus infection with nested PCR: comparison of positive rates in plasma and leukocytes and with quantitative PCR

BACKGROUND

Human cytomegalovirus (HCMV) infection poses a significant health threat to immunocompromised individuals. Here we performed this study to set up a highly sensitive nested PCR method applicable for detecting HCMV infection in high-risk individuals. In this work, 106 blood specimens from 66 patients with potential HCMV infection were obtained. Total DNA was extracted separately from plasma and peripheral blood leukocytes (PBL) of each sample. HCMV DNA was detected in parallel by nested PCR and quantitative real-time PCR (qRT-PCR), and the results were compared.

RESULTS

Serial dilution test revealed that the detection limit of nested PCR was 180 copies/ml. The nested PCR showed a higher positive rate than qRT-PCR (34.9% vs. 12.3%, p < 0.001). The positive rate of nested PCR based on PBL DNA was significantly higher than that based on plasma DNA (34.9% vs. 18.9%, p = 0.002). Of the 14 patients with serial samples, 11 were positive for HCMV DNA in PBL while only 7 were positive in plasma. Moreover, for each patient, nested PCR using PBL DNA also detected more positive samples than that using plasma DNA.

CONCLUSION

Combined use of nested PCR with PBL DNA is highly sensitive in defining HCMV infection. This assay is particularly useful in the case of quantification not essential.

Methodology for monitoring cytomegalovirus infection after renal transplantation

BACKGROUND

The aim of this study was to evaluate the diagnostic value of different detection methods for cytomegalovirus (CMV) infection after renal transplantation and also to establish a system to monitor therapy for CMV infection.

METHODS

We retrospectively studied 1516 renal transplant recipients from June 1994 to December 2006. All patients were screened for CMV-DNA. A total of 1402 patients had received CMV-IgG/IgM detection since June 1996 and 660 had received CMV antigen detection since June 2000.

RESULTS

A total of 664 (43.8%) recipients developed CMV infection. The sensitivity, specificity and Youden index of the three methods, respectively, were 18.84%, 100% and 0.1884 for ELISA, 91.86%, 82.98% and 0.7484 for PCR, and 88.06%, 96.95% and 0.8501 for the CMV-pp65 antigenemia test. The sensitivity and specificity of the two combined detection methods (CMV-DNA and CMV-pp65) for post-operation CMV infection were 93.49% and 99.06%; the two detection methods had significant dependability (p<0.05) in diagnosis of CMV infection and in evaluation of therapeutic effect of antiviral drugs.

CONCLUSIONS

Only ELISA can be used as a screening index in order to distinguish whether the donors or recipients are infected with CMV or not. CMV-pp65 antigenemia can help guide clinical therapy for CMV infection. CMV-pp65 and CMV-PCR combined together provide a more effective method to monitor CMV infection and predict its outcome.