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Keller MD, Hanley PJ, Chi YY, Aguayo-Hiraldo P, Dvorak CC, Verneris MR, Kohn DB, Pai SY, Dávila Saldaña BJ, Hanisch B, Quigg TC, Adams RH, Dahlberg A, Chandrakasan S, Hasan H, Malvar J, Jensen-Wachspress MA, Lazarski CA, Sani G, Idso JM, Lang H, Chansky P, McCann CD, Tanna J, Abraham AA, Webb JL, Shibli A, Keating AK, Satwani P, Muranski P, Hall E, Eckrich MJ, Shereck E, Miller H, Mamcarz E, Agarwal R, De Oliveira SN, Vander Lugt MT, Ebens CL, Aquino VM, Bednarski JJ, Chu J, Parikh S, Whangbo J, Lionakis M, Zambidis ET, Gourdine E, Bollard CM, Pulsipher MA. Antiviral cellular therapy for enhancing T-cell reconstitution before or after hematopoietic stem cell transplantation (ACES): a two-arm, open label phase II interventional trial of pediatric patients with risk factor assessment. Nat Commun 2024; 15:3258. [PMID: 38637498 PMCID: PMC11026387 DOI: 10.1038/s41467-024-47057-2] [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: 08/05/2023] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Viral infections remain a major risk in immunocompromised pediatric patients, and virus-specific T cell (VST) therapy has been successful for treatment of refractory viral infections in prior studies. We performed a phase II multicenter study (NCT03475212) for the treatment of pediatric patients with inborn errors of immunity and/or post allogeneic hematopoietic stem cell transplant with refractory viral infections using partially-HLA matched VSTs targeting cytomegalovirus, Epstein-Barr virus, or adenovirus. Primary endpoints were feasibility, safety, and clinical responses (>1 log reduction in viremia at 28 days). Secondary endpoints were reconstitution of antiviral immunity and persistence of the infused VSTs. Suitable VST products were identified for 75 of 77 clinical queries. Clinical responses were achieved in 29 of 47 (62%) of patients post-HSCT including 73% of patients evaluable at 1-month post-infusion, meeting the primary efficacy endpoint (>52%). Secondary graft rejection occurred in one child following VST infusion as described in a companion article. Corticosteroids, graft-versus-host disease, transplant-associated thrombotic microangiopathy, and eculizumab treatment correlated with poor response, while uptrending absolute lymphocyte and CD8 T cell counts correlated with good response. This study highlights key clinical factors that impact response to VSTs and demonstrates the feasibility and efficacy of this therapy in pediatric HSCT.
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Affiliation(s)
- Michael D Keller
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
- Division of Allergy and Immunology, Children's National Hospital, Washington, DC, USA
- GW Cancer Center, George Washington University School of Medicine, Washington, DC, USA
| | - Patrick J Hanley
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
- GW Cancer Center, George Washington University School of Medicine, Washington, DC, USA
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Yueh-Yun Chi
- Department of Pediatrics and Preventative Medicine, University of Southern California, Los Angeles, CA, USA
| | - Paibel Aguayo-Hiraldo
- Cancer and blood disease institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and BMT, University of California San Francisco, San Francisco, CA, USA
| | - Michael R Verneris
- Department of Pediatrics and Division of Child's Cancer and Blood Disorders, Children's Hospital Colorado and University of Colorado, Denver, CO, USA
| | - Donald B Kohn
- Department of Microbiology, Immunology & Molecular Genetics and Department of Pediatrics David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Division of Hematology/Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sung-Yun Pai
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Blachy J Dávila Saldaña
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Benjamin Hanisch
- Division of Pediatric Infectious Diseases, Children's National Hospital, Washington, DC, USA
| | - Troy C Quigg
- Pediatric Blood & Bone Marrow Transplant and Cellular Therapy, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Roberta H Adams
- Center for Cancer and Blood Disorders, Phoenix Children's/Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ann Dahlberg
- Clinical Research Division, Fred Hutch Cancer Center/Seattle Children's Hospital/University of Washington, Seattle, WA, USA
| | | | - Hasibul Hasan
- Cancer and blood disease institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Jemily Malvar
- Cancer and blood disease institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - Christopher A Lazarski
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Gelina Sani
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - John M Idso
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Haili Lang
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Pamela Chansky
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Chase D McCann
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Jay Tanna
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Allistair A Abraham
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
- GW Cancer Center, George Washington University School of Medicine, Washington, DC, USA
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Jennifer L Webb
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
- Division of Hematology, Children's National Hospital, Washington, DC, USA
| | - Abeer Shibli
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
| | - Amy K Keating
- Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute and Boston Children's Hospital, Boston, MA, USA
| | - Prakash Satwani
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Columbia University Medical Center, New York, NY, USA
| | - Pawel Muranski
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Columbia University Medical Center, New York, NY, USA
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, NY, USA
| | - Erin Hall
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Michael J Eckrich
- Pediatric Transplant and Cellular Therapy, Levine Children's Hospital, Wake Forest School of Medicine, Charlotte, NC, USA
| | - Evan Shereck
- Division of Hematology and Oncology, Oregon Health & Science Univ, Portland, OR, USA
| | - Holly Miller
- Center for Cancer and Blood Disorders, Phoenix Children's/Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ewelina Mamcarz
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Rajni Agarwal
- Division of Pediatric Hematology/Oncology, Stem Cell Transplantation and Regenerative Medicine, Stanford University, Palo Alto, CA, USA
| | - Satiro N De Oliveira
- Division of Hematology/Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Mark T Vander Lugt
- Division of Pediatric Hematology/Oncology/BMT, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Christen L Ebens
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota MHealth Fairview Masonic Children's Hospital, Minneapolis, MI, USA
| | - Victor M Aquino
- Division of Pediatric Hematology/Oncology, University of Texas, Southwestern Medical Center Dallas, Dallas, TX, USA
| | - Jeffrey J Bednarski
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Julia Chu
- Division of Pediatric Allergy, Immunology, and BMT, University of California San Francisco, San Francisco, CA, USA
| | - Suhag Parikh
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jennifer Whangbo
- Cancer and Blood Disorders Center, Dana Farber Institute and Boston Children's Hospital, Boston, MA, USA
| | - Michail Lionakis
- Laboratory of Clinical Immunology & Microbiology, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Elias T Zambidis
- Pediatric Blood and Marrow Transplantation Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Gourdine
- Cancer and blood disease institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Catherine M Bollard
- Center for Cancer & Immunology Research, Children's National Hospital, Washington, DC, USA
- GW Cancer Center, George Washington University School of Medicine, Washington, DC, USA
- Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, DC, USA
| | - Michael A Pulsipher
- Division of Pediatric Hematology/Oncology, Intermountain Primary Children's Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT, USA.
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2
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Cuvelier GDE, Paulson K, Bow EJ. Updates in hematopoietic cell transplant and cellular therapies that enhance the risk for opportunistic infections. Transpl Infect Dis 2023; 25 Suppl 1:e14101. [PMID: 37461887 DOI: 10.1111/tid.14101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/21/2023] [Accepted: 06/28/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Infectious disease physicians may be asked to evaluate and manage a variety of infections in immunocompromised hosts undergoing hematopoietic cell transplant (HCT) and cellular therapies. Over the last decade, several advances in cellular therapy have occurred, with implications for the types of infectious complications that may be seen. AIMS The purpose of this review is to update the infectious disease physician on newer advances in HCT and cellular therapy, including haploidentical transplant, expanding indications for transplant in older individuals and children, and chimeric antigen receptor T-cells. We will review how these advances might influence infectious disease complications following HCT. We will also provide a perspective that infectious disease physicians can use to evaluate the degree of immune suppression in an individual patient to help determine the type of infections that may be encountered.
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Affiliation(s)
- Geoffrey D E Cuvelier
- Department of Paediatrics and Child Health, Section of Paediatric Haematology/Oncology-BMT, Max Rady College of Medicine, the University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Paediatric Haematology/Oncology-BMT, CancerCare Manitoba, Winnipeg, Manitoba, Canada
- Manitoba Blood and Marrow Transplant Programme, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Kristjan Paulson
- Manitoba Blood and Marrow Transplant Programme, CancerCare Manitoba, Winnipeg, Manitoba, Canada
- Section of Haematology/Oncology, Department of Internal Medicine, Max Rady College of Medicine, the University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba, Winnipeg, Manitoba, Canada
| | - Eric J Bow
- Manitoba Blood and Marrow Transplant Programme, CancerCare Manitoba, Winnipeg, Manitoba, Canada
- Section of Haematology/Oncology, Department of Internal Medicine, Max Rady College of Medicine, the University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Manitoba, Winnipeg, Manitoba, Canada
- Section of Infectious Diseases, Department of Internal Medicine, Max Rady College of Medicine, The University of Manitoba, Winnipeg, Manitoba, Canada
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3
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Wagner-Drouet E, Teschner D, Wolschke C, Janson D, Schäfer-Eckart K, Gärtner J, Mielke S, Schreder M, Kobbe G, Kondakci M, Hilgendorf I, von Lilienfeld-Toal M, Klein S, Heidenreich D, Kreil S, Verbeek M, Grass S, Ditschkowski M, Gromke T, Koch M, Lindemann M, Hünig T, Schmidt T, Rascle A, Guldan H, Barabas S, Deml L, Wagner R, Wolff D. Standardized monitoring of cytomegalovirus-specific immunity can improve risk stratification of recurrent cytomegalovirus reactivation after hematopoietic stem cell transplantation. Haematologica 2021; 106:363-374. [PMID: 31879324 PMCID: PMC7849569 DOI: 10.3324/haematol.2019.229252] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 12/18/2019] [Indexed: 12/22/2022] Open
Abstract
Recurrence of cytomegalovirus reactivation remains a major cause of morbidity and mortality following allogeneic hematopoietic stem cell transplantation. Monitoring cytomegalovirus-specific cellular immunity using a standardized assay might improve the risk stratification of patients. A prospective multicenter study was conducted in 175 intermediate- and high-risk allogeneic hematopoietic stem cell transplant recipients under preemptive antiviral therapy. Cytomegalovirus-specific cellular immunity was measured using a standardized IFN-γ ELISpot assay (T-Track® CMV). Primary aim was to evaluate the suitability of measuring cytomegalovirus-specific immunity after end of treatment for a first cytomegalovirus reactivation to predict recurrent reactivation. 40/101 (39.6%) patients with a first cytomegalovirus reactivation experienced recurrent reactivations, mainly in the high-risk group (cytomegalovirus-seronegative donor/cytomegalovirus-seropositive recipient). The positive predictive value of T-Track® CMV (patients with a negative test after the first reactivation experienced at least one recurrent reactivation) was 84.2% in high-risk patients. Kaplan-Meier analysis revealed a higher probability of recurrent cytomegalovirus reactivation in high-risk patients with a negative test after the first reactivation (hazard ratio 2.73; p=0.007). Interestingly, a post-hoc analysis considering T-Track® CMV measurements at day 100 post-transplantation, a time point highly relevant for outpatient care, showed a positive predictive value of 90.0% in high-risk patients. Our results indicate that standardized cytomegalovirus-specific cellular immunity monitoring may allow improved risk stratification and management of recurrent cytomegalovirus reactivation after hematopoietic stem cell transplantation. This study was registered at www.clinicaltrials.gov as #NCT02156479.
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Affiliation(s)
- Eva Wagner-Drouet
- Dpt of Hematology, Medical Oncology, and Pneumology, University Medical Center, Mainz, Germany
| | - Daniel Teschner
- Dpt of Hematology, Medical Oncology, and Pneumology, University Medical Center, Mainz, Germany
| | - Christine Wolschke
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
| | - Dietlinde Janson
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
| | - Kerstin Schäfer-Eckart
- Oncology, Hematology and Bone Marrow Transplantation Unit, Klinikum Nord, Nürnberg, Germany
| | - Johannes Gärtner
- Oncology, Hematology and Bone Marrow Transplantation Unit, Klinikum Nord, Nürnberg, Germany
| | - Stephan Mielke
- Department of Laboratory Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Martin Schreder
- First Department of Medicine, Center for Oncology and Hematology, Wilhelminenspital, Vienna, Austria
| | - Guido Kobbe
- Department of Hematology, University Hospital, Heinrich Heine University Düsseldorf, Germany
| | - Mustafa Kondakci
- Department of Hematology, University Hospital, Heinrich Heine University Düsseldorf, Germany
| | - Inken Hilgendorf
- Klinik f. Innere Medizin II, Abt. Haematol. und Internist. Onkologie, Univ.-Klinikum Jena, Germany
| | | | - Stefan Klein
- Dpt of Hematology and Oncology, Univ. Medical Center Mannheim, Univ. of Heidelberg, Mannheim,Germany
| | - Daniela Heidenreich
- Dpt of Hematology and Oncology, Univ. Medical Center Mannheim, Univ. of Heidelberg, Mannheim,Germany
| | - Sebastian Kreil
- Dpt of Hematology and Oncology, Univ. Medical Center Mannheim, Univ. of Heidelberg, Mannheim,Germany
| | - Mareike Verbeek
- III. Medical Department, Hematology and Oncology, Klinikum rechts der Isar, TUM, Munich, Germany
| | - Sandra Grass
- III. Medical Department, Hematology and Oncology, Klinikum rechts der Isar, TUM, Munich, Germany
| | | | - Tanja Gromke
- Innere Klinik, Tumorforschung, University Hospital Essen, Germany
| | - Martina Koch
- Dpt of Transplantation Surgery, University Medical Center of the JGU, Mainz, Germany
| | - Monika Lindemann
- Institute for Transfusion Medicine, University Hospital Essen, Germany
| | - Thomas Hünig
- Institute of Virology and Immunobiology, University Medical Center Würzburg, Germany
| | | | | | | | | | | | - Ralf Wagner
- Institute of Clinical Microbiology and Hygiene, University Medical Center Regensburg, Germany
| | - Daniel Wolff
- Dpt of Internal Medicine III, Hematology and Oncology, University Medical Center Regensburg, Germany
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4
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Mardani M, Abolghasemi S, Shabani S, Tavakoli F, Saeedi A, Parkhideh S, Hajifathali A. The association of conditioning regimen with cytomegalovirus reactivation after allogeneic hematopoietic stem cell transplantation. IRANIAN JOURNAL OF MICROBIOLOGY 2020; 12:636-643. [PMID: 33613920 PMCID: PMC7884275 DOI: 10.18502/ijm.v12i6.5040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and Objectives: Infections is yet one of the life-threatening complications of the hematopoietic stem cell transplantation (HSCT). The myeloablative and immunosuppressive conditioning regimens, which are administered before HSCT, dampen the defense capacity of the recipients’ immune systems. In this condition, opportunistic infections, especially viral infections such as cytomegalovirus (CMV) can be reactivated and cause morbidity and mortality in HSCT patients. Here, we aimed to find out any possible relationship between types of conditioning regimen and CMV reactivation in allogeneic HSCT patients. Materials and Methods: We retrospectively analyzed the data of 145 CMV-seropositive cases out of total 201 allo-HSCT patients, including age, gender, underlying disease, conditioning regimen, prophylaxis regimen and occurrence of acute graft-versus-host disease (aGVHD) to evaluate their roles in CMV reactivation. Results: Our result showed that conditioning regimen containing Busulfan and Fludarabine (P=0.003) or Cyclophospha-mide (P=0.02) significantly decrease the early CMV reactivation. Patients who developed aGVHD (P=0.003) and those who received anti-thymocyte globulin (ATG) as prophylaxis regimen (P=0.002), had 1.84 and 2.63 times higher risks of CMV reactivation, respectively. Conclusion: Our findings suggest the conditioning regimen, aGVHD and ATG as influencing factors for early CMV reactivation post-HSCT which should be considered in the future studies.
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Affiliation(s)
- Masoud Mardani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medial Sciences, Tehran, Iran
| | - Sara Abolghasemi
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medial Sciences, Tehran, Iran
| | - Shiva Shabani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medial Sciences, Tehran, Iran
| | - Farzaneh Tavakoli
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Anahita Saeedi
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayeh Parkhideh
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Hajifathali
- Hematopoietic Stem Cell Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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5
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Ottaviano G, Lucchini G, Breuer J, Furtado-Silva JM, Lazareva A, Ciocarlie O, Elfeky R, Rao K, Amrolia PJ, Veys P, Chiesa R. Delaying haematopoietic stem cell transplantation in children with viral respiratory infections reduces transplant-related mortality. Br J Haematol 2019; 188:560-569. [PMID: 31566733 PMCID: PMC7161889 DOI: 10.1111/bjh.16216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/31/2019] [Indexed: 01/05/2023]
Abstract
Viral respiratory infections (VRIs) contribute to the morbidity and transplant‐related mortality (TRM) after allogeneic haematopoietic stem cell transplantation (HSCT) and strategies to prevent and treat VRIs are warranted. We monitored VRIs before and after transplant in children undergoing allogeneic HSCT with nasopharyngeal aspirates (NPA) and assessed the impact on clinical outcome. Between 2007 and 2017, 585 children underwent 620 allogeneic HSCT procedures. Out of 75 patients with a positive NPA screen (12%), transplant was delayed in 25 cases (33%), while 53 children started conditioning with a VRI. Patients undergoing HSCT with a positive NPA screen had a significantly lower overall survival (54% vs. 79%) and increased TRM (26% vs. 7%) compared to patients with a negative NPA. Patients with a positive NPA who delayed transplant and cleared the virus before conditioning had improved overall survival (90%) and lower TRM (5%). Pre‐HSCT positive NPA was the only significant risk factor for progression to a lower respiratory tract infection and was a major risk factor for TRM. Transplant delay, whenever feasible, in case of a positive NPA screen for VRIs can positively impact on survival of children undergoing HSCT.
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Affiliation(s)
- Giorgio Ottaviano
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Department of Paediatrics, University of Milano-Bicocca, San Gerardo Hospital/Fondazione MBBM, Monza, Italy
| | - Giovanna Lucchini
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Judith Breuer
- Department of Microbiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Division of Infection and Immunity, University College London, London, UK
| | - Juliana M Furtado-Silva
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Arina Lazareva
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Oana Ciocarlie
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Reem Elfeky
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kanchan Rao
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Persis J Amrolia
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Paul Veys
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Robert Chiesa
- Bone Marrow Transplantation Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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6
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Agrawal S, Khokhar A, Gupta S. Cytomegalovirus Colitis in Primary Hypogammaglobulinemia With Normal CD4+ T Cells: Deficiency of CMV-Specific CD8+ T Cells. Front Immunol 2019; 10:399. [PMID: 30899266 PMCID: PMC6416218 DOI: 10.3389/fimmu.2019.00399] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 02/15/2019] [Indexed: 02/03/2023] Open
Abstract
CMV colitis has been reported in immunocompromized patients with severe deficiency of CD4+ T cells and T cell functions. In this study we present an extensive immunological analysis in a patient with primary hypogammaglobulinemia and CMV colitis who had normal numbers of CD3+T, CD4+T and CD8+T cells, and normal T cell proliferative responses to mitogens and recall antigens. Naïve (TN), central (TCM), and effector (TEM) memory subsets of CD4+ and CD8+ T cells, Granzyme+ and Perforin+ CD8+ T cells, PD-1+ T cells, CD4 Treg, CD8 Treg, and CMV tetramer specific CD8+ T cells were analyzed with specific antibodies and isotype controls using multicolor flow cytometry. CD8 TEM, Granzyme+ and Perforin+, and PD-1 CD8+T cells were increased, whereas CD8 TN and CD8 TCM cells were decreased in the patient as compared to controls. CMV tetramer+ CD8+ T cells were decreased in the patient. These data demonstrate that a deficiency of CMV-specific CD8+ T cells even in the presence of normal CD4+ T cell numbers and normal T cell functions may predispose patients with primary hypogammaglobulinemia to CMV colitis.
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Affiliation(s)
- Sudhanshu Agrawal
- Program in Primary Immunodeficiency and Aging, Division of Basic and Clinical Immunology, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, University of California, Irvine, Irvine, CA, United States
| | - Amrita Khokhar
- Program in Primary Immunodeficiency and Aging, Division of Basic and Clinical Immunology, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, University of California, Irvine, Irvine, CA, United States
| | - Sudhir Gupta
- Program in Primary Immunodeficiency and Aging, Division of Basic and Clinical Immunology, Jeffrey Modell Diagnostic Center for Primary Immunodeficiencies, University of California, Irvine, Irvine, CA, United States
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7
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Neumann T, Schneidewind L, Thiele T, Pink D, Schulze M, Schmidt C, Krüger W. No indication of increased infection rates using low-dose alemtuzumab instead of anti-thymocyte globulin as graft-versus-host disease prophylaxis before allogeneic stem cell transplantation. Transpl Infect Dis 2017; 20. [PMID: 29178248 DOI: 10.1111/tid.12822] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 08/20/2017] [Accepted: 08/25/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Alemtuzumab as part of the conditioning protocol is effective in reducing graft-versus-host disease (GvHD), but may be associated with increased infection rates, especially when using high doses (ie, 100 mg). METHODS We performed a retrospective, single-center, case-control study analyzing the rates of neutropenic fever, cytomegalovirus (CMV) reactivation, Epstein-Barr virus (EBV) reactivation, clinical manifest toxoplasmosis, and clinical manifest human herpesvirus-6 (HHV6) infection using low-dose alemtuzumab in comparison with anti-thymocyte globulin (ATG) as GvHD prophylaxis before allogeneic stem cell transplantation. Forty-four patients transplanted from unrelated donors between 2001 and 2012 were matched by age, diagnosis, and conditioning regimen and treated either with alemtuzumab 10 mg at day -2 (respectively, 20 mg in case of mismatch transplantation) or ATG. ATG Fresenius (10 mg/kg for 3 days) or Thymoglobulin (2 mg/kg for 3 days) were used. RESULTS Rates of CMV reactivation, EBV reactivation, and clinical manifest HHV6 infection or toxoplasmosis did not differ significantly between both groups until 2 years after transplantation. No case of post-transplant lymphoproliferative disorder was observed. Also, rates of neutropenic fever during inpatient treatment after transplantation did not differ significantly in both groups. CONCLUSION We saw no indication of increased infections rates when using low-dose alemtuzumab as GvHD prophylaxis before allogeneic stem cell transplantation in this retrospective analysis.
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Affiliation(s)
- Thomas Neumann
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Laila Schneidewind
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - Daniel Pink
- Department of Haematology, Oncology, HELIOS Klinikum Bad Saarow, Bad Saarow, Germany
| | - Meike Schulze
- Department of Internal Medicine, Wolgast Hospital, Wolgast, Germany
| | - Christian Schmidt
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
| | - William Krüger
- Department of Haematology, Oncology, Transplantation, University Medical Centre, Ernst-Moritz-Arndt University, Greifswald, Germany
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8
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Dropulic LK, Lederman HM. Overview of Infections in the Immunocompromised Host. Microbiol Spectr 2016; 4:10.1128/microbiolspec.DMIH2-0026-2016. [PMID: 27726779 PMCID: PMC8428766 DOI: 10.1128/microbiolspec.dmih2-0026-2016] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 12/12/2022] Open
Abstract
Understanding the components of the immune system that contribute to host defense against infection is key to recognizing infections that are more likely to occur in an immunocompromised patient. In this review, we discuss the integrated system of physical barriers and of innate and adaptive immunity that contributes to host defense. Specific defects in the components of this system that predispose to particular infections are presented. This is followed by a review of primary immunodeficiency diseases and secondary immunodeficiencies, the latter of which develop because of a specific illness or condition or are treatment-related. The effects of treatment for neoplasia, autoimmune diseases, solid organ and stem cell transplants on host defenses are reviewed and associated with susceptibility to particular infections. In conclusion, an approach to laboratory screening for a suspected immunodeficiency is presented. Knowledge of which host defects predispose to specific infections allows clinicians to prevent, diagnose, and manage infections in their immunocompromised patients most effectively.
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Affiliation(s)
- Lesia K Dropulic
- The National Institutes of Health, National Institute of Allergy and Infectious Diseases, Division of Intramural Research, Bethesda, MD 20892
| | - Howard M Lederman
- Departments of Pediatrics, Medicine, and Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287
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9
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Mehta RS, Rezvani K. Immune reconstitution post allogeneic transplant and the impact of immune recovery on the risk of infection. Virulence 2016; 7:901-916. [PMID: 27385018 DOI: 10.1080/21505594.2016.1208866] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Infection is the leading cause of non-relapse mortality after allogeneic haematopoietic cell transplantation (HCT). This occurs as a result of dysfunction to the host immune system from the preparative regimen used prior to HCT, combined with a delay in reconstitution of the donor-derived immune system after HCT. In this article, we elaborate on the process of immune reconstitution post-HCT that begins with the innate system and is followed by recovery of adaptive immunity. Simultaneously, we describe how the tempo of immune reconstitution influences the risk of various infections. We explain some of the key differences in immune reconstitution and the consequent risk of infections in recipients of peripheral blood stem cell, bone marrow or umbilical cord blood grafts. Other factors that impact on immune recovery are also highlighted. Finally, we allude to various strategies that are being tested to enhance immune reconstitution post-HCT.
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Affiliation(s)
- Rohtesh S Mehta
- a Division of Hematology, Oncology and Transplantation, University of Minnesota , Minneapolis , MN , USA
| | - Katayoun Rezvani
- b Department of Stem Cell Transplantation and Cellular Therapy , MD Anderson Cancer Center , Houston , TX , USA
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10
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TALEN-mediated genetic inactivation of the glucocorticoid receptor in cytomegalovirus-specific T cells. Blood 2015; 126:2781-9. [PMID: 26508783 DOI: 10.1182/blood-2015-08-664755] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/16/2015] [Indexed: 01/11/2023] Open
Abstract
Cytomegalovirus (CMV) infection is responsible for substantial morbidity and mortality after allogeneic hematopoietic stem cell transplant. T-cell immunity is critical for control of CMV infection, and correction of the immune deficiency induced by transplant is now clinically achievable by the adoptive transfer of donor-derived CMV-specific T cells. It is notable, however, that most clinical studies of adoptive T- cell therapy exclude patients with graft-versus-host disease (GVHD) from receiving systemic corticosteroid therapy, which impairs cellular immunity. This group of patients remains the highest clinical risk group for recurrent and problematic infections. Here, we address this unmet clinical need by genetic disruption of the glucocorticoid receptor (GR) gene using electroporation of transcription activator-like effector nuclease (TALEN) messenger RNA. We demonstrate efficient inactivation of the GR gene without off-target activity in Streptamer-selected CMV-specific CD8(+) T cells (HLA-A02/NLV peptide), conferring resistance to glucocorticoids. TALEN-modified CMV-specific T cells retained specific killing of target cells pulsed with the CMV peptide NLV in the presence of dexamethasone (DEX). Inactivation of the GR gene also conferred resistance to DEX in a xenogeneic GVHD model in sublethally irradiated NOD-scid IL2rγ(null) mice. This proof of concept provides the rationale for the development of clinical protocols for producing and administering high-purity genetically engineered virus-specific T cells that are resistant to the suppressive effects of corticosteroids.
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11
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Early detection of cytomegalovirus-specific cytotoxic T lymphocytes against cytomegalovirus antigenemia in human leukocyte antigen haploidentical hematopoietic stem cell transplantation. Ann Hematol 2015; 94:1707-15. [DOI: 10.1007/s00277-015-2446-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
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12
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Hall S, Danby R, Osman H, Peniket A, Rocha V, Craddock C, Murphy M, Chaganti S. Transfusion in CMV seronegative T-depleted allogeneic stem cell transplant recipients with CMV-unselected blood components results in zero CMV transmissions in the era of universal leukocyte reduction: a U.K. dual centre experience. Transfus Med 2015; 25:418-23. [PMID: 26114211 DOI: 10.1111/tme.12219] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 03/30/2015] [Accepted: 06/03/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To establish rates of cytomegalovirus (CMV) transmission with use of CMV-unselected (CMV-U), leukocyte-reduced blood components transfused to CMV-seronegative patient/CMV-seronegative donor (CMV neg/neg) allogeneic stem cell transplantation (SCT) recipients including those receiving T-depleted grafts. BACKGROUND CMV infection remains a major cause of morbidity following SCT. CMV-seronegative SCT recipients are particularly at risk of transfusion transmitted CMV (TT-CMV) and until recently they have received blood components from CMV-seronegative donors with significant resource implications. Although leukocyte reduction of blood components is reported to minimise risk of TT-CMV, its efficacy in high-risk situations, such as in T-depleted transplant recipients, is unknown. METHODS We retrospectively analysed the incidence of TT-CMV in CMV neg/neg allogeneic SCT recipients transfused with CMV-U, leukocyte-reduced blood components in two transplantation centres in the UK. Patients were monitored for CMV infection by weekly CMV polymerase chain reaction testing. Leukocyte reduction of blood components was in accordance with current UK standards. RESULTS Among 76 patients, including 59 receiving in vivo T-depletion, no episodes of CMV infection were detected. Patients were transfused with 1442 CMV-unselected, leukocyte-reduced components, equating to 1862 donor exposures. CONCLUSIONS Our findings confirm the safety of leukocyte reduction as a strategy in preventing TT-CMV in high-risk allogeneic SCT recipients.
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Affiliation(s)
- S Hall
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - R Danby
- Department of Haematology, Oxford University Hospitals, Oxford, UK
| | - H Osman
- Department of Virology, University Hospitals Birmingham, Birmingham, UK
| | - A Peniket
- Department of Haematology, Oxford University Hospitals, Oxford, UK
| | - V Rocha
- Department of Haematology, Oxford University Hospitals, Oxford, UK
| | - C Craddock
- Department of Clinical Haematology, University Hospitals Birmingham, Birmingham, UK
| | - M Murphy
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - S Chaganti
- Department of Clinical Haematology, University Hospitals Birmingham, Birmingham, UK
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13
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Saif MA, Borrill R, Bigger BW, Lee H, Logan A, Poulton K, Hughes S, Turner AJ, Bonney DK, Wynn RF. In vivo T-cell depletion using alemtuzumab in family and unrelated donor transplantation for pediatric non-malignant disease achieves engraftment with low incidence of graft vs. host disease. Pediatr Transplant 2015; 19:211-8. [PMID: 25546609 DOI: 10.1111/petr.12416] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 11/30/2022]
Abstract
In vivo T-cell depletion, using alemtuzumab therapy prior to SCT, can reduce the incidence of GVHD. This treatment has a potential to delay immune reconstitution resulting in increased morbidity due to viral illnesses. We retrospectively analyzed data on all pediatric patients with non-malignant disorders who received alemtuzumab-based conditioning regimens in our center over the last 10 yr (n = 91). Our data show an OS of 91.2%. The incidence of acute (grade 2-4) GVHD was 18.7% and that of chronic GVHD 5.5%. Viremia due to adenovirus, EBV and CMV was seen in 19.8%, 64.8% and 39.6% patients, respectively, with only two deaths attributed to viral infection (adenovirus). Chimerism level at three month was predictive of graft outcome. Nine patients, who had graft failure after first SCT, were salvaged with a second SCT using RIC and same donor (if available). Based on these results, we conclude that the use of in vivo T-cell depletion is safe, achieves good chimerism and does not lead to increased morbidity and mortality due to viral infections. It is associated with a reduced incidence of chronic GVHD.
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Affiliation(s)
- M A Saif
- Department of Blood and Marrow Transplant, Royal Manchester Children's Hospital, Manchester, UK
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14
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Outcomes of hematopoietic cell transplantation in adult patients with acquired aplastic anemia using intermediate-dose alemtuzumab-based conditioning. Biol Blood Marrow Transplant 2014; 20:1722-8. [PMID: 25017761 DOI: 10.1016/j.bbmt.2014.06.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 06/25/2014] [Indexed: 11/21/2022]
Abstract
Graft-versus-host disease (GVHD) has no therapeutic benefit after hematopoietic cell transplantation (HCT) for patients with acquired aplastic anemia (AA), and its prevention is highly desirable. We designed a conditioning regimen using an intermediate dose of alemtuzumab (50 to 60 mg) and describe our institutional experience of 41 patients who underwent HCT for AA. The median age at HCT was 37 years (range, 17 to 59). The conditioning regimen was high-dose cyclophosphamide (n = 9) or fludarabine based (n = 32). Additional GVHD prophylaxis was with cyclosporine. With a median follow-up of 3.6 years, overall survival at 3 years was 85%. Survival in patients <40 years and ≥40 years was 96% and 67%, respectively (P = .04). Graft failure occurred in 4 (10%) patients; 2 primary and 2 secondary. The cumulative incidences of acute (grades 1 to 2) and chronic GVHD were 27% and 15%, respectively. No patients developed grade 3 to 4 acute GVHD or severe chronic GVHD. The following viral complications were frequent: cytomegalovirus reactivation (79%), herpes simplex (18%), varicella zoster (25%), and BK virus hemorrhagic cystitis (8%). The majority of patients had no significant long-term health issues. This intermediate-dose alemtuzumab-based conditioning regimen results in excellent survival with a favorable impact on GVHD and long-term health outcomes, but close monitoring for viral complications is important.
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15
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Vallejo C, Ríos E, de la Serna J, Jarque I, Ferrá C, Sánchez-Godoy P, Solano C, de la Cámara R, Rosell AI, Varela R, García MD, González-Barca E, López J, Pérez E, Ferrer S, Casado LF, Vázquez L, Villalón L, García-Marco JA. Incidence of cytomegalovirus infection and disease in patients with lymphoproliferative disorders treated with alemtuzumab. Expert Rev Hematol 2014; 4:9-16. [DOI: 10.1586/ehm.10.77] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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16
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Lane JP, Evans PTG, Nademi Z, Barge D, Jackson A, Hambleton S, Flood TJ, Cant AJ, Abinun M, Slatter MA, Gennery AR. Low-dose serotherapy improves early immune reconstitution after cord blood transplantation for primary immunodeficiencies. Biol Blood Marrow Transplant 2013; 20:243-9. [PMID: 24225641 PMCID: PMC7110834 DOI: 10.1016/j.bbmt.2013.11.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 11/06/2013] [Indexed: 11/27/2022]
Abstract
Cord blood transplantation (CBT) is curative for many primary immunodeficiencies (PIDs) but is associated with risks of viral infection and graft-versus-host disease (GvHD). Serotherapy reduces GvHD but potentially increases the risk of viral infection by delaying immune reconstitution. Because many PID patients have pre-existing viral infections, the optimal dose of serotherapy is unclear. We performed a retrospective analysis in 34 consecutive PID patients undergoing CBT and compared immune reconstitution, viral infection, GvHD, mortality, and long-term immune function between high-dose (n = 11) and low-dose (n = 9) serotherapy. Serotherapy dose had no effect on neutrophil engraftment. Median CD3+ engraftment occurred at 92.5 and 97 days for high- and low-dose serotherapy, respectively. The low-dose serotherapy group had higher CD3+, CD4+, and early thymic emigrant counts at 4 months compared with the high-dose group. GvHD severity and number of viral infections did not differ between serotherapy doses. Survival from the transplantation process was 90.9% for high-dose and 100% for low-dose groups. In conclusion, low-dose serotherapy enhanced T cell reconstitution and thymopoiesis during the first year after CBT with no increase in GvHD.
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Affiliation(s)
- Jonathan P Lane
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Philippa T G Evans
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Zohreh Nademi
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Dawn Barge
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Anthony Jackson
- International Centre for Life, Newcastle upon Tyne, United Kingdom
| | - Sophie Hambleton
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Terry J Flood
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew J Cant
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Mario Abinun
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Mary A Slatter
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Andrew R Gennery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, United Kingdom.
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17
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Tey SK, Kennedy GA, Cromer D, Davenport MP, Walker S, Jones LI, Crough T, Durrant ST, Morton JA, Butler JP, Misra AK, Hill GR, Khanna R. Clinical assessment of anti-viral CD8+ T cell immune monitoring using QuantiFERON-CMV® assay to identify high risk allogeneic hematopoietic stem cell transplant patients with CMV infection complications. PLoS One 2013; 8:e74744. [PMID: 24146744 PMCID: PMC3795724 DOI: 10.1371/journal.pone.0074744] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 08/06/2013] [Indexed: 12/02/2022] Open
Abstract
The reconstitution of anti-viral cellular immunity following hematopoietic stem cell transplantation (HSCT) is crucial in preventing cytomegalovirus (CMV)-associated complications. Thus immunological monitoring has emerged as an important tool to better target pre-emptive anti-viral therapies. However, traditional laboratory-based assays are too cumbersome and complicated to implement in a clinical setting. Here we conducted a prospective study of a new whole blood assay (referred to as QuantiFERON-CMV®) to determine the clinical utility of measuring CMV-specific CD8+ T-cell responses as a prognostic tool. Forty-one evaluable allogeneic HSCT recipients underwent weekly immunological monitoring from day 21 post-transplant and of these 21 (51.2%) showed CMV reactivation and 29 (70.7%) developed acute graft-versus-host disease (GvHD). Patients with acute GvHD (grade≥2) within 6 weeks of transplant showed delayed reconstitution of CMV-specific T-cell immunity (p = 0.013) and a higher risk of CMV viremia (p = 0.026). The median time to stable CMV-specific immune reconstitution was 59 days and the incidence of CMV reactivation was lower in patients who developed this than those who did not (27% versus 65%; p = 0.031). Furthermore, a failure to reconstitute CMV-specific immunity soon after the onset of CMV viraemia was associated with higher peak viral loads (5685 copies/ml versus 875 copies/ml; p = 0.002). Hence, QuantiFERON-CMV® testing in the week following CMV viremia can be useful in identifying HSCT recipients at risk of complicated reactivation.
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Affiliation(s)
- Siok-Keen Tey
- Australian Centre for Vaccine Development and Tumour Immunology Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
- Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Glen A. Kennedy
- Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Deborah Cromer
- Complex Systems in Biology Group, Centre for Vascular Research, University of New South Wales, Kensington, New South Wales, Australia
| | - Miles P. Davenport
- Complex Systems in Biology Group, Centre for Vascular Research, University of New South Wales, Kensington, New South Wales, Australia
| | - Susan Walker
- Australian Centre for Vaccine Development and Tumour Immunology Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
| | - Linda I. Jones
- Australian Centre for Vaccine Development and Tumour Immunology Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
| | - Tania Crough
- Australian Centre for Vaccine Development and Tumour Immunology Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
| | - Simon T. Durrant
- Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - James A. Morton
- Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jason P. Butler
- Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Ashish K. Misra
- Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Geoffrey R. Hill
- Department of Haematology and Bone Marrow Transplantation, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Bone Marrow Transplant Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
| | - Rajiv Khanna
- Australian Centre for Vaccine Development and Tumour Immunology Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
- * E-mail:
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18
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Emery V, Zuckerman M, Jackson G, Aitken C, Osman H, Pagliuca A, Potter M, Peggs K, Clark A. Management of cytomegalovirus infection in haemopoietic stem cell transplantation. Br J Haematol 2013; 162:25-39. [PMID: 23647436 DOI: 10.1111/bjh.12363] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Vincent Emery
- Department of Virology; University College London School of Life and Medical Sciences; London; UK
| | - Mark Zuckerman
- Department of Virology; King's College Hospital; London; UK
| | - Graham Jackson
- Department of Haematology; Freeman Road Hospital; Newcastle; UK
| | - Celia Aitken
- West of Scotland specialist virology centre; Gartnavel General Hospital; Glasgow; UK
| | - Husam Osman
- Birmingham HPA Laboratory; Birmingham Heartlands Hospital; Birmingham; UK
| | | | - Mike Potter
- Section of Haemato-oncology; The Royal Marsden NHS Foundation Trust; London; UK
| | - Karl Peggs
- Department of Haematology; University College London Hospitals; London; UK
| | - Andrew Clark
- Blood and Marrow Transplant Unit; Beatson Oncology Centre; Glasgow; UK
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19
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Allogeneic stem cell transplantation using alemtuzumab-containing regimens in severe aplastic anemia. Int J Hematol 2013; 97:573-80. [PMID: 23632948 DOI: 10.1007/s12185-013-1333-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
Abstract
Alemtuzumab, a humanized anti-CD52, IgG1 monoclonal antibody, is used to reduce graft-versus- host disease (GVHD) and aid engraftment after allogeneic haemopoietic stem cell transplant (HSCT). Its associated low incidence of GVHD makes it an attractive alternative to anti-thymocyte globulin (ATG) in transplant conditioning regimen for severe aplastic anaemia (SAA). We have reviewed the use of alemtuzumab-based conditioning regimen for HSCT in SAA and show that it results in sustained haematological engraftment, a very low incidence of chronic GVHD without an increase in viral infections. Intriguingly, alemtuzumab appears to induce tolerance post-HSCT with the findings of stable mixed T cell chimerism with full donor myeloid chimerism and the absence of chronic GVHD, and which persist on withdrawal of post-graft immunosuppression. Finally, its low toxicity profile may permit future application of HSCT to older patients with SAA who fail to respond to immunosuppressive therapy.
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20
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Nikiforow S, Kim HT, Bindra B, McDonough S, Glotzbecker B, Armand P, Koreth J, Ho VT, Alyea EP, Blazar BR, Ritz J, Soiffer RJ, Antin JH, Cutler CS. Phase I study of alemtuzumab for therapy of steroid-refractory chronic graft-versus-host disease. Biol Blood Marrow Transplant 2013; 19:804-11. [PMID: 23416855 DOI: 10.1016/j.bbmt.2013.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 02/10/2013] [Indexed: 11/16/2022]
Abstract
Steroid-refractory chronic graft-versus-host disease (cGVHD) carries a poor prognosis with no agreed upon algorithm for treatment. Because both B and T cells contribute to the pathophysiology of cGVHD, we conducted a phase I study in subjects with steroid-refractory cGVHD using the anti-CD52 antibody alemtuzumab to transiently deplete most mononuclear subsets. Three regimens were investigated in a 3+3 dose-escalation design: 3 mg × 6 (dose level 1), 3 mg × 1, then 10 mg × 5 (dose level 2) and 3 mg × 1, 10 mg × 1, then 30 mg × 4 (dose level 3) administered over 4 weeks. The maximum tolerated dose of alemtuzumab was dose level 2. Thirteen patients were assessable for toxicities, which were primarily infectious and hematologic. Rates of infectious complications in the first 12 weeks were 0% at dose level 1 (n = 3), 50% at dose level 2 (1 death, n = 6), and 75% at dose level 3 (2 deaths, n = 4). Of 10 patients assessable for response, 7 (70%) responded at 12 weeks, with a 30% complete response rate. Four subjects reduced steroid dose or discontinued an immunosuppressant at 12 weeks. The median decrease in steroid dose at 1 year was 61.6%. Infectious complications occurred predominantly in the first 3 months after therapy, but full B and T cell recovery took well over 12 months. Immunophenotypic profiling revealed early recovery by natural killer cells and relative sparing of CD4+ and CD8+ central memory T cell subsets. Our study indicates that therapy with alemtuzumab for steroid-refractory cGVHD is tolerable with close attention to dosing and may be active in subjects who have failed multiple therapies. The pattern of lymphocyte recovery after alemtuzumab will inform the biology and future therapy of cGVHD. The use of alemtuzumab in the context of therapy for cGVHD deserves study in larger phase II trials.
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Affiliation(s)
- Sarah Nikiforow
- Division of Hematologic Malignancies, Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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21
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Hodby K, Pamphilon D. Concise review: expanding roles for hematopoietic cellular therapy and the blood transfusion services. Stem Cells 2012; 29:1322-6. [PMID: 21739527 DOI: 10.1002/stem.689] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hematopoietic stem cells (HSCs) have remained at the forefront of stem cell research for the past 50 years, since the therapeutic potential of bone marrow transplantation was realized. Uniquely, among stem and progenitor cells, research progress has been made in parallel between the laboratory benchtop and hospital bedside during this period. Integral to this work has been the role of the transfusion medicine services in the collection, storage, and processing of HSCs. The next decade promises to bring further developments: with new fields of cellular therapies, stem cell vaccination, and stem cell drug testing opening up. This article summarizes exciting areas of research concerning the behavior and potential clinical applications of HSCs. For the purposes of clarity, we describe in turn the trafficking and transfer of HSCs; ex vivo expansion of HSC units from different sources; and finally, applications of specifically selected subsets of hematopoietic cells and their progeny.
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22
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George B, Kerridge I, Gilroy N, Huang G, Hertzberg M, Bradstock K, Gottlieb D. A risk score for early cytomegalovirus reactivation after allogeneic stem cell transplantation identifies low-, intermediate-, and high-risk groups: reactivation risk is increased by graft-versus-host disease only in the intermediate-risk group. Transpl Infect Dis 2012; 14:141-8. [DOI: 10.1111/j.1399-3062.2011.00706.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Revised: 09/22/2011] [Accepted: 10/19/2011] [Indexed: 11/27/2022]
Affiliation(s)
- B. George
- Department of Haematology; University of Sydney; Westmead Hospital; Sydney New South Wales Australia
| | - I.H. Kerridge
- Department of Haematology; University of Sydney; Westmead Hospital; Sydney New South Wales Australia
| | - N. Gilroy
- Department of Infectious Diseases; University of Sydney; Westmead Hospital; Sydney New South Wales Australia
| | - G. Huang
- Department of Haematology; University of Sydney; Westmead Hospital; Sydney New South Wales Australia
| | - M.S. Hertzberg
- Department of Haematology; University of Sydney; Westmead Hospital; Sydney New South Wales Australia
| | - K.F. Bradstock
- Department of Haematology; University of Sydney; Westmead Hospital; Sydney New South Wales Australia
| | - D.J. Gottlieb
- Department of Medicine; University of Sydney; Westmead Hospital; Sydney New South Wales Australia
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23
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Poiré X, van Besien K. Alemtuzumab in allogeneic hematopoetic stem cell transplantation. Expert Opin Biol Ther 2011; 11:1099-111. [PMID: 21702703 DOI: 10.1517/14712598.2011.592824] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION With the use of reduced-intensity conditioning (RIC), early toxicity of allogeneic stem cell transplantation (SCT) has been much reduced. Graft-versus-host disease (GvHD) causes morbidities and mortality. Alemtuzumab is a mAb directed against CD52. When administered prior to transplant, it leads to T-cell depletion. Incorporation of alemtuzumab in RIC results in low rates of GvHD and treatment-related mortality (TRM) in haematological diseases, even in the setting of mismatched-donor transplantation. AREAS COVERED The use of alemtuzumab for GvHD prophylaxis in SCT. The benefit of alemtuzumab-based conditioning is partially offset by increased disease relapse due to impaired graft-versus-tumor effect (GvT) and by slower immune reconstitution, necessitating special precautions. While GvHD is prevented with alemtuzumab, post-SCT interventions are often required. Most studies find that alemtuzumab-based conditioning results in decreased chronic GvHD and TRM, but also in decreased progression-free survival. Overall survival after 3 - 5 years is usually equivalent and quality of life may be improved because of a lower incidence of sequelae of chronic GvHD. Many aspects of alemtuzumab treatment are under investigation. EXPERT OPINION Alemtuzumab reduces GvHD and TRM after SCT. Use of alemtuzumab requires awareness and strict management of the risk of opportunistic infections and of an increased risk of disease recurrence.
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Affiliation(s)
- Xavier Poiré
- Section of Hematology, Department of Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 10 avenue Hippocrate, 1200 Brussels, Belgium
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Recovery of CMV-Specific CD8+ T Cells and Tregs after Allogeneic Peripheral Blood Stem Cell Transplantation. Biol Blood Marrow Transplant 2011; 17:550-7. [DOI: 10.1016/j.bbmt.2010.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 04/19/2010] [Indexed: 11/21/2022]
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Perales MA. Adoptive Therapy of Cytomegalovirus-Specific T Lymphocytes: Is Less More? Clin Infect Dis 2011; 52:58-60. [DOI: 10.1093/cid/ciq055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, and Weill Medical College of Cornell University, New York, New York
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George B, Kerridge I, Gilroy N, Huang G, Hertzberg M, Gottlieb D, Bradstock K. Fludarabine-based reduced intensity conditioning transplants have a higher incidence of cytomegalovirus reactivation compared with myeloablative transplants. Bone Marrow Transplant 2009; 45:849-55. [PMID: 19915635 DOI: 10.1038/bmt.2009.273] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Two hundred and ten adult CMV seropositive patients undergoing myeloablative conditioning (MAC) [n=127] or reduced intensity conditioning (RIC) [n=83] transplants (HCT) were serially monitored for CMV reactivation and disease, using a qualitative polymerase chain reaction (PCR) followed by quantitation with pp65 antigen or quantitative PCR. CMV reactivation occurred in 53 RIC (63.9%) and 61 MAC (48%; P=0.03) transplants at a median of 47 days (range: 24-1977). Risk factors identified included acute GVHD (P=0.001), RIC regimen (P=0.03), unrelated donor (P=0.02), use of anti-thymocyte globulin/alemtuzumb (P=0.02) and use of bone marrow in MAC transplants (P=0.011). On multivariate analysis, RIC transplants and acute GVHD remained independent predictors. Treatment with antiviral drugs resulted in CMV negativity rates of 86.8% in MAC and 88.6% in RIC transplants. CMV disease occurred in 10.8% of RIC and 4.7% of MAC transplants (P=0.15). At a median follow-up of 26 months (range: 3-88), 48.1% of RIC and 50.3% of MAC transplants are alive. The higher incidence of CMV reactivation among RIC transplants suggests the need for novel prophylactic or pre-emptive strategies in this high-risk group of patients.
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Affiliation(s)
- B George
- Department of Haematology, Level II ICPMR, Westmead Hospital, Sydney, New South Wales, Australia.
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Park S, Choi SM, Lee DG, Choi JH, Yoo JH, Kim SH, Kim HJ, Cho SG, Eom KS, Lee JW, Min WS, Shin WS, Kim CC. Infectious complications associated with alemtuzumab use for allogeneic hematopoietic stem cell transplantation: comparison with anti-thymocyte globulin. Transpl Infect Dis 2009; 11:413-23. [DOI: 10.1111/j.1399-3062.2009.00414.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bertz H, Spyridonidis A, Wäsch R, Grüllich C, Egger M, Finke J. A novel GVHD-prophylaxis with low-dose alemtuzumab in allogeneic sibling or unrelated donor hematopoetic cell transplantation: the feasibility of deescalation. Biol Blood Marrow Transplant 2009; 15:1563-70. [PMID: 19896080 DOI: 10.1016/j.bbmt.2009.08.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 08/02/2009] [Indexed: 12/01/2022]
Abstract
Prophylaxis of acute graft-versus-host disease (aGVHD), while maintaining the graft-versus-leukemia (GVL)/lymphoma effect and preventing severe infectious diseases, remains the main challenge in allogeneic hematopoetic cell transplantation (allo-HCT). To evaluate this, we examined the feasibility of deescalating the dose of alemtuzumab (MabCampath) in combination with cyclosporine (CsA) as the sole GVHD-prophylaxis in patients after fludarabine (Flu)-based reduced-intensity conditioning (RIC) in an observational cohort study. We included 127 consecutive patients (median age 63 years) with an unrelated (UD; n=69) or related donor (SIB; n=58) after their first transplantation, mostly presenting with advanced disease. The first 30 patients received 20 mg/day on day -2 and -1 (40 mg), the following 48 patients 10 mg/day on day -2 and -1 (20 mg), and the last 49 patients 10 mg on day -1 (10 mg) alemtuzumab intravenous (i.v.) prior to transplant. We observed no statistical differences comparing the 40 mg, 20 mg, or 10 mg dose groups, in terms of cumulative incidences of aGVHD grade III-IV 7% (confidence interval [CI] 95%; 1-51), 12% (1-40), 6% (1-40), extensive chronic GVHD (cGVHD) 24.4% (3.3-55.8), 17% (2.5-42), and 14.2% (1.5-41.5) and of aGVHD grade II-IV 7 % (0-51.5), 29% (11.9-49.1), 21% (15.3-43.1), respectively. The difference between the 20-mg and 40-mg groups was significant for aGVHD grade II-IV(P < .05). In conclusion, we demonstrate the feasibility of reducing the dose of alemtuzumab as GVHD-prophylaxis to 10 mg absolute in combination with CsA only for UD transplantation in particular.
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Affiliation(s)
- Hartmut Bertz
- Albert Ludwigs-University Medical Center Freiburg, Department of Hematology and Oncology, Freiburg, Germany
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Early reconstitution of effector memory CD4+ CMV-specific T cells protects against CMV reactivation following allogeneic SCT. Bone Marrow Transplant 2008; 43:853-61. [PMID: 19104497 DOI: 10.1038/bmt.2008.403] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Reactivation of CMV is a common complication following allogeneic haematopoietic SCT and is associated with significant morbidity and mortality. The relative importance of the CD4+ and CD8+ components of the CMV-specific immune response in protection from reactivation is unclear. The CMV-specific CD4+ and CD8+ immune response was measured at serial time points in 32 patients following allogeneic HSCT. Intracellular cytokine staining following CMV lysate stimulation and HLA-peptide tetramers were used to determine CMV-specific CD4+ and CD8+ responses, respectively. A deficient CMV-specific CD4+ T-cell immune response within the first 30-50 days post transplant was associated with high risk of viral reactivation. Patients with combined impairment of the CD4+ and CD8+ immune response within the first 100 days were susceptible to late viral reactivation. The frequency of CMV-specific CD4+ T cells correlated with CMV-specific CD8+ T cells, comprising 10% of the whole T-cell repertoire. Early CMV-specific CD4+ T-cell reconstitution was dominated by effector memory cells with normal levels of IL-2 resuming 6 months following transplantation. In summary, both CD4 and CD8 CMV-specific immune reconstitution is required for protection from recurrent activation. Measurement of the magnitude of the CMV-specific CD4+ immune response is useful in managing viral reactivation following HSCT.
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Kennedy-Nasser AA, Bollard CM, Myers GD, Leung KS, Gottschalk S, Zhang Y, Liu H, Heslop HE, Brenner MK, Krance RA. Comparable outcome of alternative donor and matched sibling donor hematopoietic stem cell transplant for children with acute lymphoblastic leukemia in first or second remission using alemtuzumab in a myeloablative conditioning regimen. Biol Blood Marrow Transplant 2008; 14:1245-52. [PMID: 18940679 DOI: 10.1016/j.bbmt.2008.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Accepted: 08/22/2008] [Indexed: 11/19/2022]
Abstract
HLA-matched sibling donor (MSD) stem cell transplantation can cure>60% of pediatric patients with acute lymphoblastic leukemia (ALL), but <30% of patients will have a sibling donor. Alternative donor (AD) transplantation can be curative but has a higher risk of graft-versus-host disease (GVHD). The addition of alemtuzumab (Campath 1-H) to AD transplants produces in vivo T cell depletion, which may reduce the risk for GVHD. We now report the outcome for 83 children with ALL (41 MSD, 42 AD) undergoing stem cell transplantation in first or second complete remission. All patients received myeloablative conditioning, including cyclophosphamide, cytarabine arabinoside, and total-body irradiation, with alemtuzumab administered to AD recipients. GVHD prophylaxis consisted of a calcineurin inhibitor with either short-course methotrexate or prednisone. Disease-free survival (DFS) for MSD recipients was 72.3% (95% confidence interval [CI], 55.4%-83.6%) versus 62.4% (95% CI, 45.2%-75.4%) for AD recipients. The 100-day mortality was 7.1% in the AD group and 2.4% in the MSD group. Relapse rates were identical (24%). Treatment-related mortality, principally viral infection, explained the difference in survival. For children undergoing stem cell transplantation (SCT) from alternative donors, alemtuzumab with a myeloablative conditioning regimen resulted in DFS comparable to MSD.
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Affiliation(s)
- Alana A Kennedy-Nasser
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
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Alemtuzumab markedly reduces chronic GVHD without affecting overall survival in reduced-intensity conditioning sibling allo-SCT for adults with AML. Bone Marrow Transplant 2008; 43:709-15. [PMID: 19029965 DOI: 10.1038/bmt.2008.375] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
By retrospective analysis of 88 patients from the British Society of Blood and Marrow Transplantation registry, we investigated the effect of in vivo T-cell depletion in HLA-identical sibling reduced-intensity conditioning (RIC) allografts for adult AML by comparing patients who received alemtuzumab with those without alemtuzumab conditioning. Both groups were equivalent for age, sex, karyotype and disease status at transplant. With a median follow-up of 27 months (3-72 months) and 48 months (7-72 months), the 2- and 5-year overall survival, with or without alemtuzumab, is 60 and 60% (P=0.80) and 61 and 53%, respectively (P=0.85). The 2-year non-relapse mortality is 12% with alemtuzumab, and 17% without alemtuzumab (P=0.49). The 2-year relapse rate is 35% with alemtuzumab compared with 19% without alemtuzumab (P=0.28). Grades II-IV acute GVHD occurred in 22% (8/37) without alemtuzumab compared with 14% (7/51) given alemtuzumab (P=0.25). Extensive chronic GVHD occurred in 47% (14/30) not given alemtuzumab compared with 4% (2/45) who were given alemtuzumab (P=0.001). Among evaluable patients, the risk of infections was higher in those treated with alemtuzumab compared with those not treated with alemtuzumab (79 vs 57%, respectively, P=0.02). In conclusion, alemtuzumab has a beneficial effect by reducing chronic GVHD without affecting overall survival. Further studies are warranted before alemtuzumab can be recommended as standard in RIC allografts for AML.
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Chae YS, Sohn SK, Kim JG, Cho YY, Moon JH, Yang DH, Lee JJ, Kim YK, Kim HJ, Shin HJ, Chung JS, Cho GJ. Impact of alemtuzumab as conditioning regimen component on transplantation outcomes in case of CMV-seropositive recipients and donors. Am J Hematol 2008; 83:649-53. [PMID: 18528826 DOI: 10.1002/ajh.21215] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We studied the incidence of cytomegalovirus (CMV) infection, clinical outcomes, and complications in 39 recipients of alemtuzumab-containing conditioning-stem cell transplantation, who were classified into two groups based on the median dose (35 mg) of alemtuzumab. All the recipients and donors were CMV-seropositive before transplantation. The median survival duration was 321 days (range, 46-1098 days) and the 2-year survival rate was 47.8%. The probability of nonrelapse mortality at 100 days and 2 years was 14.6% and 31.2%, respectively. The cumulative incidence of Grade II-IV acute graft-versus-host disease (GVHD) at Day 100 was 21.8%. The overall incidence of chronic GVHD (cGVHD) was 28.6%, including a 17.9% incidence of extensive cGVHD. The cumulative incidence of CMV antigenemia was 68.0%. There were no statistical differences in the engraftment, acute and cGVHD, relapse, CMV antigenemia, and overall survival (OS) between the two groups. Yet, the nonrelapse mortality (NRM) was significantly lower for the low-dose group (5.9% vs. 51.7%, P = 0.010). The present study showed that alemtuzumab was effective for GVHD prevention, yet caused a relatively high incidence of CMV antigenemia, regardless of the dose. Thus, a low dose of alemtuzumab (< or = 35 mg) would seem to be preferable in an allogeneic SCT setting when both the recipient and the donor are CMV seropositive.
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Affiliation(s)
- Yee Soo Chae
- Department of Hematology/Oncology, Kyungpook National University Hospital, Daegu, Korea
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Alcaide ML, Abbo L, Pano JR, Gaynor JJ, Tryphonopoulos P, Weppler D, Moon JI, Tzakis AG, Morris MI. Herpes zoster infection after liver transplantation in patients receiving induction therapy with alemtuzumab. Clin Transplant 2008; 22:502-7. [DOI: 10.1111/j.1399-0012.2008.00816.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Cohen JM, Cooper N, Chakrabarti S, Thomson K, Samarasinghe S, Cubitt D, Lloyd C, Woolfrey A, Veys P, Amrolia PJ. EBV-related disease following haematopoietic stem cell transplantation with reduced intensity conditioning. Leuk Lymphoma 2007; 48:256-69. [PMID: 17325885 DOI: 10.1080/10428190601059837] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The use of reduced intensity regimens has decreased early mortality following stem cell transplantation. However, the increased immunosuppression following these protocols results in profound and often prolonged lymphopenia, resulting in an increased incidence of viral reactivation. We and others have observed a high incidence of EBV viraemia and post-transplant lymphoproliferative disease (PTLD) following reduced-intensity conditioning regimens, reflecting the delayed recovery of EBV-specific immunity after such transplants. The clinical and histological features at presentation are similar to that seen after conventional intensity conditioning. Given the increasing use of reduced intensity conditioning (RIC) transplants, we review the risk factors for EBV related disease following transplantation with RIC, the potential for pre-emptive therapy of PTLD based on monitoring EBV viraemia and management options in such patients.
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Affiliation(s)
- Jonathan M Cohen
- Department of Bone Marrow Transplantation, Great Ormond Street Hospital, NHS Trust, London, UK
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35
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Micklethwaite K, Hansen A, Foster A, Snape E, Antonenas V, Sartor M, Shaw P, Bradstock K, Gottlieb D. Ex vivo expansion and prophylactic infusion of CMV-pp65 peptide-specific cytotoxic T-lymphocytes following allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2007; 13:707-14. [PMID: 17531781 DOI: 10.1016/j.bbmt.2007.02.004] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Accepted: 02/12/2007] [Indexed: 10/23/2022]
Abstract
Cytomegalovirus reactivation and infection post-allogeneic hematopoietic stem cell transplant continue to cause morbidity and mortality. Current pharmacologic therapies are limited by side effects. Adoptive transfer of ex vivo generated cytomegalovirus-specific T cells has the potential to restore immunity, prevent cytomegalovirus, and circumvent the need for pharmacologic therapies. We have generated donor-derived cytomegalovirus-specific cytotoxic T cells using dendritic cells pulsed with the HLA-A2 restricted nonapeptide NLVPMVATV (NLV) derived from the cytomegalovirus-pp65 protein. These cytotoxic T cells have been given prophylactically to 9 recipients aged 4 to 65 years on or after day 28 post-allogeneic hematopoietic stem cell transplant. Only 2 of 9 recipients received T cell depletion in vivo or in vitro. There were no immediate adverse reactions to the infusions. During 97-798 days of follow-up, 2 recipients developed cytomegalovirus reactivation; neither developed cytomegalovirus disease or required pharmacotherapy. Three recipients developed acute graft versus host disease after infusion. Two recipients died, 1 from thrombotic thrombocytopenia purpura secondary to cyclosporine, 1 from complications of graft versus host disease. A transient increase in numbers of cytomegalovirus-specific T cells demonstrated by NLV-tetramer binding was seen in 6 recipients. Prophylactic adoptive transfer of NLV-specific T cells is safe and may be effective in preventing cytomegalovirus reactivation.
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Affiliation(s)
- Kenneth Micklethwaite
- Westmead Millennium Institute, University of Sydney at Westmead Hospital, Sydney, Australia
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Borthakur G, Lin E, Faderl S, Ferrajoli A, Wierda W, Giles F, Browning ML, Kantarjian H, Keating M, O'Brien S. Low serum albumin level is associated with cytomegalovirus reactivation in patients with chronic lymphoproliferative diseases treated with alemtuzumab (Campath-1H)-based therapies. Cancer 2007; 110:2478-83. [DOI: 10.1002/cncr.23031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Kennedy-Nasser AA, Leung KS, Mahajan A, Weiss HL, Arce JA, Gottschalk S, Carrum G, Khan SP, Heslop HE, Brenner MK, Bollard CM, Krance RA. Comparable Outcomes of Matched-Related and Alternative Donor Stem Cell Transplantation for Pediatric Severe Aplastic Anemia. Biol Blood Marrow Transplant 2006; 12:1277-84. [PMID: 17162209 DOI: 10.1016/j.bbmt.2006.07.011] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Accepted: 07/20/2006] [Indexed: 10/23/2022]
Abstract
Matched sibling donor (MSD) bone marrow transplantation is the treatment of choice for pediatric patients with severe aplastic anemia (SAA); however, only about 33% of patients will have an HLA-identical sibling. Alternative donor (AD) transplants may be an option for these patients, but such therapies have been associated with greater incidence of graft failure and graft-versus-host disease (GVHD). We retrospectively analyzed 36 pediatric patients who received 38 bone marrow or peripheral blood stem cell transplants (15 MSD and 23 AD) for SAA at our institution from April 1997 to October 2005. Nineteen AD recipients received reduced intensity conditioning with cyclophosphamide, low-dose total body irradiation, and antithymocyte globulin (ATG) or Campath. The 4-year overall survival for MSD recipients was 93% versus 89% for AD recipients treated with reduced intensity conditioning regimens at a median follow-up of 52 months (range, 6-99 months). No patient receiving Campath, compared with 3 of 9 patients receiving ATG, developed extensive, chronic GVHD. We conclude that, for children with SAA, AD transplantation is as effective as MSD transplantation. Further, compared with ATG, preparatory regimens containing Campath may be associated with a lower incidence of extensive, chronic GHVD.
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Affiliation(s)
- Alana A Kennedy-Nasser
- Center for Cell and Gene Therapy, Baylor College of Medicine, The Methodist Hospital and Texas Children's Hospital, Houston, Texas 77030, USA.
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Johnston B, Conly J. Alemtuzumab and natalizumab: the monoclonal antibody story continues. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2006; 17:327-9. [PMID: 18382646 PMCID: PMC2095094 DOI: 10.1155/2006/876252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Accepted: 11/06/2006] [Indexed: 01/01/2023]
Abstract
In the July/August 2006 issue of this journal, the infectious complications associated with the use of infliximab, etanercept and adalimumab were reviewed (1). These represent only three of the many monoclonal antibodies either licensed or in clinical trials for therapeutic use in cancer and autoimmune disease or to prevent rejection in both solid organ and hematopoietic stem cell transplantation. While most of these agents have not been associated with increased infection rates, alemtuzumab and natalizumab have gained particular attention related to either the frequency or type of infection seen in some individuals who have received them.
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Affiliation(s)
- Bl Johnston
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
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Baron F, Storer B, Maris MB, Storek J, Piette F, Metcalf M, White K, Sandmaier BM, Maloney DG, Storb R, Boeckh M. Unrelated Donor Status and High Donor Age Independently Affect Immunologic Recovery after Nonmyeloablative Conditioning. Biol Blood Marrow Transplant 2006; 12:1176-87. [PMID: 17085311 DOI: 10.1016/j.bbmt.2006.07.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Accepted: 07/10/2006] [Indexed: 12/27/2022]
Abstract
The risk of cytomegalovirus (CMV) infection is higher after HLA-matched unrelated donor (URD) than after HLA-matched related donor (MRD) nonmyeloablative hematopoietic cell transplantation (HCT). We therefore investigated factors affecting immune recovery in 94 patients given HCT from MRDs (n = 51) and URDs (n = 43) after 2-Gy total body irradiation with or without fludarabine and postgrafting immunosuppression with mycophenolate mofetil and cyclosporine. CD4 T cells counts remained below normal values during the first year after HCT in both patient groups. This included abnormally low counts each of naive CD4 T cells and memory CD4 T cells. Conversely, CD8 T cell counts reached the 10th percentile of normal 6 months after HCT in MRD and URD recipients. On day 30 after HCT, URD recipients had lower counts of B cells (P = .02), naive CD4 T cells (P = .04), memory CD4 T cells (P = .005), memory CD8 T cells (P = .005), and CMV-specific T helper cells (P = .007) than had MRD recipients. This delay in CMV-specific immune reconstitution translated into increased frequency of CMV antigenemia among URD recipients during the first 100 days after HCT. Older donor age was associated with low counts of naive CD4 T cells on days 180-365 after HCT (P = .003). Further, low numbers of T cells and CD34(+) cells in the graft and development of acute graft-versus-host disease were associated with impaired immune recovery of naive CD4 T cells and B cells. In summary, immunologic recovery was poor the first year after nonmyeloablative conditioning and was delayed among URD recipients in comparison with MRD recipients. Other factors significantly associated with delayed immune recovery were advanced donor age, low numbers of CD34 and T cells in the graft, and development of graft-versus-host disease.
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Affiliation(s)
- Frédéric Baron
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109-6072, USA
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Brunstein CG, Weisdorf DJ, DeFor T, Barker JN, Tolar J, van Burik JAH, Wagner JE. Marked increased risk of Epstein-Barr virus-related complications with the addition of antithymocyte globulin to a nonmyeloablative conditioning prior to unrelated umbilical cord blood transplantation. Blood 2006; 108:2874-80. [PMID: 16804113 PMCID: PMC1895580 DOI: 10.1182/blood-2006-03-011791] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Umbilical cord blood (UCB) is increasingly used as an alternative source of hematopoietic stem cells for transplantation for patients who lack a suitable sibling donor. Despite concerns about a possible increased risk of Epstein-Barr virus (EBV) posttransplantation lymphoproliferative disorder (PTLD) after UCB transplantation, early reports documented rates of PTLD comparable to those reported after HLA-matched unrelated marrow myeloablative (MA) transplantations. To further investigate the incidence of EBV PTLD after UCB transplantation and potential risk factors, we evaluated the incidence of EBV-related complications in 335 patients undergoing UCB transplantation with an MA or nonmyeloablative (NMA) preparative regimen. The incidence of EBV-related complications was a 4.5% overall, 3.3% for MA transplantations, and 7% for NMA transplantations. However, the incidence of EBV-related complications was significantly higher in a subset of patients treated with an NMA preparative regimen that included antithymocyte globulin (ATG) versus those that did not (21% vs 2%; P < .01). Nine of 11 patients who developed EBV PTLD were treated with rituximab (anti-CD20 antibody), with the 5 responders being alive and disease free at a median of 26 months. Use of ATG in recipients of an NMA preparative regimen warrants close monitoring for evidence of EBV reactivation and potentially preemptive therapy with rituximab.
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Affiliation(s)
- Claudio G Brunstein
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA.
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Bego MG, St Jeor S. Human cytomegalovirus infection of cells of hematopoietic origin: HCMV-induced immunosuppression, immune evasion, and latency. Exp Hematol 2006; 34:555-70. [PMID: 16647557 DOI: 10.1016/j.exphem.2005.11.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Revised: 11/15/2005] [Accepted: 11/21/2005] [Indexed: 12/16/2022]
Affiliation(s)
- Mariana G Bego
- Department of Microbiology and Immunology, University of Nevada, Reno, Reno, NV 89557, USA
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