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Martinez S, Sindu D, Nailor MD, Cherrier L, Tokman S, Walia R, Goodlet KJ. Evaluating the efficacy and safety of letermovir compared to valganciclovir for the prevention of human cytomegalovirus disease in adult lung transplant recipients. Transpl Infect Dis 2024:e14279. [PMID: 38742601 DOI: 10.1111/tid.14279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/05/2024] [Accepted: 03/27/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Lung transplant recipients are at high risk for severe cytomegalovirus (CMV) disease. Off-label use of letermovir (LET) may avert myelotoxicity associated with valganciclovir (VGCV), but data in lung transplantation are limited. This study aims to evaluate the outcomes of LET prophylaxis among lung transplant recipients. METHODS This retrospective, matched cohort study included lung transplant recipients who received LET for primary CMV prophylaxis following VGCV intolerance. Patients were matched 1:1 to historical VGCV controls based on age, serostatus group, and time from transplant. The primary outcome was CMV breakthrough within 1 year post-LET initiation; secondary outcomes included hematologic changes. RESULTS A total of 124 lung transplant recipients were included per group (32% CMV mismatch, D+R-), with LET initiated a median of 9.6 months post-transplantation. One CMV breakthrough event (0.8%) was observed in the LET group versus four (3.2%) in the VGCV group (p = .370). The median (interquartile range) white blood cell (WBC) count was 3.1 (2.1-5.6) at LET initiation which increased to 5.1 (3.9-7.2) at the end of follow-up (p <.001). For VGCV controls, WBC was 4.8 (3.4-7.2) at baseline and 5.4 (3.6-7.2) at the end of follow-up; this difference was not statistically significant (p = .395). Additionally, 98.4% of LET patients experienced ≥1 leukopenia episode in the year prior to LET compared to 71.8% the year after initiation (p <.001). Similar results were observed for neutropenia (48.4% and 17.7%, p <.001). CONCLUSION LET prophylaxis was associated with a low rate of CMV reactivation and leukopenia recovery. LET may represent a reasonable prophylaxis option for lung transplant recipients unable to tolerate VGCV.
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Affiliation(s)
- Sydni Martinez
- Department of Pharmacy Services, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Devika Sindu
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael D Nailor
- Department of Pharmacy Services, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Lauren Cherrier
- Department of Pharmacy Services, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Sofya Tokman
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Rajat Walia
- Division of Transplant Pulmonology, Norton Thoracic Institute, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kellie J Goodlet
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale, Arizona, USA
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Piccirilli G, Lanna F, Gabrielli L, Motta V, Franceschiello M, Cantiani A, Pavoni M, Leone M, Borgatti EC, Gibertoni D, Pascale R, Giannella M, Bonifazi F, Lazzarotto T. CMV-RNAemia as new marker of active viral replication in transplant recipients. J Clin Microbiol 2024; 62:e0163023. [PMID: 38534109 PMCID: PMC11078005 DOI: 10.1128/jcm.01630-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Affiliation(s)
- Giulia Piccirilli
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federica Lanna
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Liliana Gabrielli
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Vincenzo Motta
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | | | - Alessia Cantiani
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Matteo Pavoni
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Marta Leone
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Eva Caterina Borgatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Dino Gibertoni
- Research and Innovation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Renato Pascale
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesca Bonifazi
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia “Seràgnoli”, Bologna, Italy
| | - Tiziana Lazzarotto
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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3
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Saltiel G, Faure E, Assaf A, Chopin MC, Moreau F, Faure K, Goeminne C, Vuotto F. Real-life use of letermovir prophylaxis for cytomegalovirus in heart transplant recipients. Clin Transplant 2024; 38:e15327. [PMID: 38686437 DOI: 10.1111/ctr.15327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) remains the predominant opportunistic infection following solid organ transplantation (SOT). While valganciclovir is the drug of choice for CMV prophylaxis, its utility can be compromised due to the risk of cytopenia. Letermovir, a novel agent approved for CMV prophylaxis in allogeneic hematopoietic stem cell transplant recipients and high-risk kidney transplant recipients, exhibits reduced toxicity. This study aims to present the practical application of letermovir as both primary and secondary prophylaxis against CMV in heart transplant recipients (HTR). METHODS In this observational, retrospective, single-center study, we included all consecutive adult HTRs from June 2020 to January 2022 who were administered letermovir for CMV prophylaxis. We documented instances of CMV breakthrough infections, side effects related to letermovir, changes in neutropenia following the switch from valganciclovir to letermovir, and any drug interactions with the immunosuppressive regimen. RESULTS The study comprised 10 patients: two received primary prophylaxis with letermovir due to a high risk of CMV infection (donor-positive, recipient-negative serostatus), and eight received it as secondary prophylaxis following a CMV infection. The median duration of letermovir administration was 8 months (range 3-12 months). No CMV breakthrough infections were reported while on prophylaxis. However, three patients experienced CMV breakthrough infections after discontinuing letermovir prophylaxis (30%). No significant side effects were observed, although one patient reported digestive intolerance. Among the nine patients on tacrolimus, six needed reduced doses after switching to letermovir. CONCLUSION This real-life study appears to support the effectiveness of letermovir prophylaxis in HTR. Nonetheless, the risk of CMV infection post-treatment cessation is notable. Further drug monitoring and research on the efficacy of letermovir for CMV prophylaxis in SOT patients is warranted.
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Affiliation(s)
- Grégoire Saltiel
- CHU Lille, Service Universitaire de Maladies Infectieuses, Lille, France
| | - Emmanuel Faure
- CHU Lille, Service Universitaire de Maladies Infectieuses, Lille, France
- Univ. Lille, U1019-UMR 9017-CIIL-Center for Infection and Immunity of Lille, Lille, France
| | - Ady Assaf
- CHU Lille, Service Universitaire de Maladies Infectieuses, Lille, France
| | | | | | - Karine Faure
- CHU Lille, Service Universitaire de Maladies Infectieuses, Lille, France
- Univ. Lille, U1019-UMR 9017-CIIL-Center for Infection and Immunity of Lille, Lille, France
| | - Céline Goeminne
- CHU Lille, Unité de Transplantation et Assistance Cardiaque, Lille, France
| | - Fanny Vuotto
- CHU Lille, Service Universitaire de Maladies Infectieuses, Lille, France
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Ohmoto A, Fuji S. Letermovir for cytomegalovirus infection in allogeneic hematopoietic stem-cell transplantation: tips and notes for effective use in clinical practice. Expert Rev Anti Infect Ther 2024; 22:169-178. [PMID: 38404258 DOI: 10.1080/14787210.2024.2322439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/20/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection remains a major complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). While conventional antiviral agents such as ganciclovir can be used for CMV prophylaxis, toxicities such as myelosuppression are a major concern. AREA COVERED This work aimed to summarize the latest information and practical issues regarding a new anti-CMV agent, letermovir (LET). EXPERT OPINION LET inhibits CMV replication by binding to components of the DNA terminase complex. A phase 3 trial in allo-HSCT recipients showed a reduced incidence of clinically significant CMV infection in the LET group. In 2017, this agent was first approved for CMV prophylaxis in adult CMV-seropositive allo-HSCT recipients in the United States, and is now used worldwide. While LET has an excellent toxicity profile, there are issues to be aware of, such as interactions with other drug classes (e.g. immunosuppressants and antifungals) and reactivation of CMV infection following LET cessation. While LET is the current standard of care for CMV prophylaxis, there are no established protocols for preemptive treatment of asymptomatic CMV viremia or for treatment of developed CMV disease. Further research is needed to maximize the benefits of LET, including the discovery of biomarkers.
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Affiliation(s)
- Akihiro Ohmoto
- Department of Medical Oncology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shigeo Fuji
- Department of Hematology, Osaka International Cancer Institute, Osaka, Japan
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Galaverna F, Baccelli F, Zama D, Tridello G, Masetti R, Soncini E, Mura R, Barzaghi F, Colombini A, Prunotto G, D'Amico MR, Calore E, Biffi A, Perruccio K, Gasperini P, Oltolini C, Quagliarella F, Giacomazzi A, Pagliara D, Locatelli F, Cesaro S. Letermovir for Cytomegalovirus infection in pediatric patients undergoing allogenic hematopoietic stem cell transplantation: a real-life study by the Infectious Diseases Working Group of Italian Association of Pediatric Hematology-Oncology (AIEOP). Bone Marrow Transplant 2024; 59:505-512. [PMID: 38272999 DOI: 10.1038/s41409-024-02209-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
Letermovir prophylaxis revolutionized the approach to Cytomegalovirus infection in adult hematopoietic stem cell transplant (HCT), while data in pediatric setting are still lacking. We retrospectively analyzed 87 HCT children transplanted in 11 AIEOP centers receiving letermovir as off-label indication between January 2020 and November 2022. Letermovir was used as primary, secondary prophylaxis or CMV treatment in 39, 26 and 22 cases, respectively; no discontinuation due to toxicity was reported. Median duration was 100 days (14-256) for primary and 96 days (8-271) for secondary prophylaxis, respectively. None of the patients experienced CMV-clinically significant reactivation during Letermovir primary prophylaxis; one patient developed breakthrough infection during secondary prophylaxis, and 10 and 1 patient experienced asymptomatic CMV-reactivation and CMV-primary infection after drug discontinuation, respectively. Median duration of letermovir in CMV treatment was 40 days (7-134), with 4/22 patients suffering CMV-pneumonia, with an overall response rate of 86.4%. With a median follow-up of 10.7 months (8.2-11.8), estimated 1-year overall survival was 86%; no CMV-related deaths were reported in prophylaxis groups. This is the largest report on Letermovir use in pediatric HCT; real-life data confirm an excellent toxicity profile, with high efficacy as CMV prophylaxis; results in CMV-infection treatment should be investigated in larger, prospective trials.
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Affiliation(s)
- Federica Galaverna
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy.
| | - Francesco Baccelli
- Department of Medical and surgical sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Daniele Zama
- Department of Medical and surgical sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gloria Tridello
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo Masetti
- Department of Medical and surgical sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Pediatric Hematology and Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elena Soncini
- Pediatric Oncohematology and Bone marrow transplant Unit, ASST Spedali Civili, Brescia, Italy
| | - Rossella Mura
- Pediatric Hematology Oncology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Federica Barzaghi
- Pediatric Immunohematology Unit and bone marrow transplant Unit, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Antonella Colombini
- Department of Pediatrics, Fondazione MBBM - Ospedale San Gerardo, Monza, Italy
| | - Giulia Prunotto
- Department of Pediatrics, Fondazione MBBM - Ospedale San Gerardo, Monza, Italy
| | - Maria Rosaria D'Amico
- Unità Operativa di Trapianto di Cellule Staminali Ematopoietiche e Terapie Cellulari, AORN Santobono-Pausilipon, Napoli, Italy
| | - Elisabetta Calore
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Alessandra Biffi
- Pediatric Hematology, Oncology and Stem Cell Transplant Division, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Katia Perruccio
- Pediatric Oncology Hematology, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Pietro Gasperini
- Department of Pediatrics, Azienda Unità Sanitaria Locale di Rimini, Rimini, Italy
| | - Chiara Oltolini
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Francesco Quagliarella
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Alice Giacomazzi
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Daria Pagliara
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Franco Locatelli
- Department of Pediatric Oncology, Hematology, Cell and Gene Therapy, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
- Catholic University of the Sacred Heart, Roma, Italy
| | - Simone Cesaro
- Pediatric Hematology Oncology, Department of Mother and Child, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
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Giménez E, Gozalbo-Rovira R, Albert E, Piñana JL, Solano C, Navarro D. Letermovir use may impact on the Cytomegalovirus DNA fragmentation profile in plasma from allogeneic hematopoietic stem cell transplant recipients. J Med Virol 2024; 96:e29564. [PMID: 38506145 DOI: 10.1002/jmv.29564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 03/21/2024]
Abstract
Cytomegalovirus (CMV) DNA in plasma is mainly unprotected and highly fragmented. The size of the amplicon largely explains the variation in CMV DNA loads quantified across PCR platforms. In this proof-of-concept study, we assessed whether the CMV DNA fragmentation profile may vary across allogeneic hematopoietic stem cell transplant recipients (allo-SCT), within the same patient over time, or is affected by letermovir (LMV) use. A total of 52 plasma specimens from 14 nonconsecutive allo-SCT recipients were included. The RealTime CMV PCR (Abbott Molecular), was used to monitor CMV DNA load in plasma, and fragmentation was assessed with a laboratory-designed PCR generating overlapping amplicons (around 90-110 bp) within the CMV UL34, UL80.5, and UL54 genes. Intrapatient, inter-patient, and LMV-associated qualitative and quantitative variations in seven amplicons were observed. These variations were seemingly unrelated to the CMV DNA loads measured by the Abbott PCR assay. CMV DNA loads quantified by UL34_4, UL54.5, and UL80.5_1 PCR assays discriminate between LMV and non-LMV patients. Our observations may have relevant implications in the management of active CMV infection in allo-SCT recipients, either treated or not with LMV, although the data need further validation.
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Affiliation(s)
- Estela Giménez
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
| | | | - Eliseo Albert
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
| | - José Luis Piñana
- Hematology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
| | - Carlos Solano
- Hematology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
- Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - David Navarro
- Microbiology Service, Clinic University Hospital, INCLIVA Health Research Institute, Valencia, Spain
- Department of Microbiology School of Medicine, University of Valencia, Valencia, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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Kotton CN, Torre-Cisneros J, Yakoub-Agha I. Slaying the "Troll of Transplantation"-new frontiers in cytomegalovirus management: A report from the CMV International Symposium 2023. Transpl Infect Dis 2024; 26:e14183. [PMID: 37942955 DOI: 10.1111/tid.14183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/10/2023]
Abstract
The 2023 International CMV Symposium took place in Barcelona in May 2023. During the 2-day meeting, delegates and faculty discussed the ongoing challenge of managing the risk of cytomegalovirus infection (the Troll of Transplantation) after solid organ or hematopoietic cell transplantation. Opportunities to improve outcomes of transplant recipients by applying advances in antiviral prophylaxis or pre-emptive therapy, immunotherapy, and monitoring of cell-mediated immunity to routine clinical practice were debated and relevant educational clinical cases presented. This review summarizes the presentations, cases, and discussions from the meeting and describes how further advances are needed before the Troll of Transplantation is slain.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain
- CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
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8
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Li WW, Zhang YM, Shen MZ, Mo XD. Efficacy and safety of letermovir prophylaxis for cytomegalovirus infection after hematopoietic stem cell transplantation. Blood Sci 2024; 6:e00178. [PMID: 38213825 PMCID: PMC10781138 DOI: 10.1097/bs9.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/22/2023] [Indexed: 01/13/2024] Open
Abstract
Letermovir is a specific inhibitor of cytomegalovirus (CMV) terminase complex. Several studies have reported that letermovir can effectively prevent CMV activation after allogeneic hematopoietic stem cell transplantation (allo-HSCT). We aimed to identify the efficacy and safety of letermovir prophylaxis for CMV infection after allo-HSCT with a systemic review and meta-analysis. A literature search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. PubMed and Embase databases were searched. A total of 28 studies were included. The incidence of CMV activation at 14 weeks after HSCT was 0.10 (95% confidence interval [CI], 0.06-0.18), which was 0.10 (95% CI, 0.04-0.21) and 0% in adult and children (2 studies were included and both of them were 0%). In addition, the incidence of CMV activation at 14 weeks after allo-HSCT was 0.11 (95% CI, 0.06-0.21) and 0.07 (only 1 study included), respectively, in retrospective and prospective studies. The incidence of CMV activation at 100 and 200 days after HSCT was 0.23 (95% CI, 0.16-0.33) and 0.49 (95% CI, 0.32-0.67), respectively. The incidence of CMV disease at 14 weeks and at 6 months after HSCT was 0.01 (95% CI, 0.01-0.02) and 0.03 (95% CI, 0.01-0.09), respectively. Thus, our systemic review and meta-analysis suggested that letermovir prophylaxis was safe and effective for CMV activation after allo-HSCT.
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Affiliation(s)
- Wen-Wen Li
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Department of Hematology, Qingdao Women and Children’s Hospital, Qingdao, China
| | - Yong-Mei Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Department of Hematology, Shijiazhuang People’s Hospital, Shijiazhuang, China
| | - Meng-Zhu Shen
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Dong Mo
- Peking University People’s Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies (2019RU029), Chinese Academy of Medical Sciences, Beijing, China
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9
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Roberts MB, Kotton CN. Letermovir Prophylaxis After Kidney Transplantation: Another Tool but Not a Revolution Yet. Transplantation 2024; 108:7-9. [PMID: 38098156 DOI: 10.1097/tp.0000000000004809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Matthew B Roberts
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Camille N Kotton
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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10
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Moore WJ, Boutin CA, Tanna S. A new direction for cytomegalovirus prophylaxis among transplant recipients: Benefits and nonviral outcomes of letermovir use as primary CMV prophylaxis. Curr Opin Infect Dis 2023; 36:514-521. [PMID: 37773928 DOI: 10.1097/qco.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
PURPOSE OF REVIEW Letermovir has changed the game of primary prophylaxis against cytomegalovirus (CMV) for hematopoietic stem cell transplant (HSCT) and more recently, solid organ transplant recipients. This is largely due to letermovir's similar efficacy in protecting against CMV reactivation and disease, along with its superior safety profile, notably reduced myelotoxicity, and lack of renal dose adjustment compared to standard agents like valganciclovir. This review will describe the potential benefits and clinical considerations of letermovir as prophylaxis among transplant recipients, with a focus on recent evidence describing nonviral outcomes of CMV. RECENT FINDINGS Recent evidence has demonstrated improved safety (e.g., less myelosuppression) and tolerability with no difference in rates of CMV infection or disease in kidney transplant recipients given letermovir compared to valganciclovir. Real-world studies and meta-analyses in HSCT populations have explored various nonviral outcomes with letermovir use. Letermovir prophylaxis was associated with reduced mortality, lower rates of graft versus host disease, delayed CMV immune reconstitution, improved tolerability with extended durations, and decreased healthcare utilization. SUMMARY Letermovir is an effective antiviral agent for CMV prevention and has demonstrated enhanced safety, which may allow for extended durations of primary prophylaxis among transplant recipients along with other improved clinical outcomes by mitigating the indirect effects of CMV.
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Affiliation(s)
- W Justin Moore
- Department of Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - Catherine-Audrey Boutin
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Sajal Tanna
- Division of Infectious Disease, Department of Medicine, Inova Medical Group, Falls Church, Virginia, USA
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11
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Yong MK, Slavin MA, Chemaly RF, Papanicolaou GA. CMV prevention strategies in allogeneic hematopoietic cell transplantation; the role of prophylaxis and pre-emptive monitoring in the era of letermovir. Transpl Infect Dis 2023; 25 Suppl 1:e14171. [PMID: 37864299 DOI: 10.1111/tid.14171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 10/22/2023]
Abstract
The preferred strategy for preventing CMV in at-risk populations in alloHCT has undergone a significant practice shift in recent years where the pendulum has swung from a pre-emptive approach to now offering letermovir prophylaxis to all CMV seropositive recipients. Letermovir prophylaxis has resulted in significant reductions in post-transplant clinically significant CMV infection (csCMVi) as well as other important outcomes such as CMV disease, resistant, and refractory CMV infections and nonrelapse mortality. However, prophylactic strategies are not without some limitations, namely delayed onset CMV infections, delayed CMV-specific T cell immune reconstitution, increased drug costs and limited data within pediatric populations. Thus, this review aims to provide an overview of prophylaxis and pre-emptive CMV preventative strategies, and how they are applicable in the current era of letermovir prophylaxis.
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Affiliation(s)
- Michelle K Yong
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Infectious Diseases, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Centre, Houston, Texas, USA
| | - Genovefa A Papanicolaou
- Department of Medicine, Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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12
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Orofino G, Xue E, Doglio M, Noviello M, Tassi E, Cristante M, Acerbis A, Clerici D, Farina F, Campodonico E, Bruno A, Piemontese S, Mastaglio S, Diral E, Milani R, Ruggeri A, Corti C, Vago L, Bonini C, Peccatori J, Ciceri F, Lupo Stanghellini MT, Greco R. Dynamics of polyclonal immuno-reconstitution after allogeneic transplant with post-transplant cyclophosphamide and letermovir. Bone Marrow Transplant 2023; 58:1104-1111. [PMID: 37468541 DOI: 10.1038/s41409-023-02046-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 07/21/2023]
Abstract
Cytomegalovirus (CMV) reactivations are strong stimulators of immune-reconstitution (IR) in hematopoietic stem cell transplantation (HSCT) recipients. Herein, we analyzed 317 CMV-seropositive consecutive patients (n = 109 letermovir, LTV; n = 208 no-LTV), undergoing HSCT with post-transplant cyclophosphamide (PTCy) and calcineurin inhibitor- (CNI) free graft-versus-host-disease (GvHD) prophylaxis. At day+90, median CD19+/mm3 was higher in LTV-cohort: 5.5 [0;439] versus 2 [0;294], p = 0.008; median CD3+/mm3 counts were lower in LTV-cohort, with no differences in CD4+, CD8+ and NK-cells. At day+180 median CD3+, CD4+ and CD8+/mm3 values were comparable between groups. Higher CD19+/mm3 counts were observed in LTV-cohort: 62 [0; 2983] versus 42 [0; 863]. Significantly higher median NK/mm3 values were seen in LTV-cohort: 225.5 [0;763] versus 163.5 [0;1181], p = 0.0003. The impact of LTV on B-cell IR at 3 months and NK-cell levels at 6 months was retained in multivariate analysis (p < 0.01), whereas the effect on T-cells was not confirmed. Moreover, we confirmed a significant reduction of clinically-relevant CMV, and moderate-to- severe chronic GvHD in LTV-cohort. Overall, in our study the use of LTV was associated with a slight improvement of B-cell and NK-cells reconstitution, with only minor impact on T-cell subsets, giving new insights on polyclonal IR for HSCT recipients in the LTV era.
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Affiliation(s)
- Giorgio Orofino
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Elisabetta Xue
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Matteo Doglio
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Maddalena Noviello
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Cell Therapy Immunomonitoring Laboratory (MITiCi), Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Hospital, Milano, Italy
| | - Elena Tassi
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Cell Therapy Immunomonitoring Laboratory (MITiCi), Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Hospital, Milano, Italy
| | | | - Andrea Acerbis
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Daniela Clerici
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Francesca Farina
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Edoardo Campodonico
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Alessandro Bruno
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
| | - Simona Piemontese
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Sara Mastaglio
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Elisa Diral
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Raffaella Milani
- Immunohematology and Transfusion Medicine Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Annalisa Ruggeri
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Consuelo Corti
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Luca Vago
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Università Vita-Salute San Raffaele, Milano, Italy
- Unit of Immunogenetics, Leukemia Genomics and Immunobiology IRCCS San Raffaele Hospital, Milano, Italy
| | - Chiara Bonini
- Università Vita-Salute San Raffaele, Milano, Italy
- Experimental Hematology Unit, IRCCS San Raffaele Hospital, Milano, Italy
- Cell Therapy Immunomonitoring Laboratory (MITiCi), Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Hospital, Milano, Italy
| | - Jacopo Peccatori
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy
| | - Fabio Ciceri
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy.
- Università Vita-Salute San Raffaele, Milano, Italy.
| | | | - Raffaella Greco
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Hospital, Milano, Italy.
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Nho D, Lee R, Cho SY, Lee DG, Kim EJ, Park S, Lee SE, Cho BS, Kim YJ, Lee S, Kim HJ. Cytomegalovirus Infection after Allogeneic Hematopoietic Cell Transplantation under 100-Day Letermovir Prophylaxis: A Real-World 1-Year Follow-Up Study. Viruses 2023; 15:1884. [PMID: 37766290 PMCID: PMC10536589 DOI: 10.3390/v15091884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/03/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
The prevention and management of cytomegalovirus (CMV) reactivation is important to improve the outcomes of allogeneic hematopoietic cell transplantation (allo-HCT) recipients. The aim of this study was to analyze real-world data regarding the incidence and characteristics of CMV infections until 1 year after allo-HCT under 100-day letermovir prophylaxis. A single-center retrospective study was conducted between November 2020 and October 2021. During the study period, 358 patients underwent allo-HCT, 306 of whom received letermovir prophylaxis. Cumulative incidence of clinically significant CMV infection (CS-CMVi) was 11.4%, 31.7%, and 36.9% at 14 weeks, 24 weeks, and 1 year post-HCT, respectively. Through multivariate analysis, the risk of CS-CMVi increased with graft-versus-host disease (GVHD) ≥ grade 2 (adjusted odds ratio 3.640 [2.036-6.510]; p < 0.001). One-year non-relapse mortality was significantly higher in letermovir breakthrough CS-CMVi patients than those with subclinical CMV reactivation who continued receiving letermovir (p = 0.002). There were 18 (15.9%) refractory CMV infection cases in this study population. In summary, letermovir prophylaxis is effective at preventing CS-CMVi until day 100, which increased after the cessation of letermovir. GVHD is still a significant risk factor in the era of letermovir prophylaxis. Further research is needed to establish individualized management strategies, especially in patients with significant GVHD or letermovir breakthrough CS-CMVi.
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Affiliation(s)
- Dukhee Nho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.N.); (R.L.); (D.-G.L.)
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Raeseok Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.N.); (R.L.); (D.-G.L.)
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.N.); (R.L.); (D.-G.L.)
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.N.); (R.L.); (D.-G.L.)
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Eun-Jin Kim
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Silvia Park
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Sung-Eun Lee
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Byung-Sik Cho
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Yoo-Jin Kim
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Seok Lee
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
| | - Hee-Je Kim
- Catholic Hematology Hospital, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (E.-J.K.); (S.P.); (S.-E.L.); (B.-S.C.); (Y.-J.K.); (S.L.); (H.-J.K.)
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Sepassi A, Saunders IM, Bounthavong M, Taplitz RA, Logan C, Watanabe JH. Effectiveness of letermovir for cytomegalovirus prophylaxis in allogeneic hematopoietic stem cell transplant recipients: A global systematic review. J Am Pharm Assoc (2003) 2023; 63:1138-1149. [PMID: 37207713 DOI: 10.1016/j.japh.2023.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/30/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE(S) Letermovir (LET), a novel antiviral, has largely supplanted more traditional preemptive therapy (PET) for cytomegalovirus (CMV) prophylaxis in allogeneic hematopoietic stem cell transplant (allo-HCT) patients. Use of LET demonstrated efficacy against placebo in phase III randomized controlled trials, but is considerably more expensive than PET. This review aimed to evaluate the real-world effectiveness of LET in preventing clinically significant CMV infection (csCMVi) for allo-HCT recipients and related outcomes. DESIGN A systematic literature review was performed using an a priori protocol using PubMed, Scopus, and ClinicalTrials.gov from January 2010 to October 2021. SETTING AND PARTICIPANTS Studies were included if they met the following criteria: LET compared with PET, CMV-related outcomes, patients aged 18 years or older, and English language-only articles. Descriptive statistics were used to summarize study characteristics and outcomes. OUTCOME MEASURES CMV viremia, csCMVi, CMV end-organ disease, graft-versus-host-disease, all-cause mortality. RESULTS A total of 233 abstracts were screened, with 30 included in this review. Randomized trials demonstrated efficacy of LET prophylaxis in preventing csCMVi. Observational studies demonstrated varying degrees of effectiveness of LET prophylaxis compared with use of PET alone. All studies with a comparator group resulted in lower rates of csCMVi for patients using LET. Included studies varied widely by CMV viral load threshold cutoff and CMV test units, limiting synthesis of results owing to high heterogeneity. CONCLUSION LET reduces risk of csCMVi, but lack of standardized clinical definitions on how to evaluate csCMVi and related outcomes largely prevent synthesis of results. Clinicians must consider this limitation in the context of evaluating the effectiveness of LET to other antiviral therapies, especially for patients at risk of late-onset CMV. Future studies should focus on prospective data collection through registries and concordance of diagnostic definitions to mitigate study heterogeneity.
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Zavaglio F, Vitello D, Bergami F, Arena F, Borsani O, Colombo AA, Caldera D, Lilleri D, Cassaniti I, Bernasconi P, Baldanti F. Human Cytomegalovirus (HCMV) - specific T-cell response after letermovir prophylaxis is predictive for subsequent HCMV reactivation in haematopoietic stem cell transplant recipients. J Clin Virol 2023; 165:105519. [PMID: 37321150 DOI: 10.1016/j.jcv.2023.105519] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Human Cytomegalovirus (HCMV) is still one of the major concerning infection in hematopoietic stem cell transplant (HSCT) recipients. Letermovir (LTV) has been recently introduced for HCMV prophylaxis in adult patients who received allogeneic HSCT. However, many aspects related to immune reconstitution need to be further explored. The aim of this study was to define the prognostic role of HCMV-specific T-cell frequency measured at the end of LTV prophylaxis in predicting the risk for clinically significant HCMV infection (i.e. infection requiring antiviral treatment) after the stop of the prophylaxis. METHODS Sixty-six adult patients who underwent allogeneic HSCT were enrolled and HCMV DNAemia was prospectively monitored. Additionally, HCMV-specific T-cell response was evaluated using ELISpot assay against two different antigens (HCMV infected cell lysate and pp65 peptide pool). RESULTS Ten patients (15.2%) developed at least one positive HCMV DNAemia episode during LTV prophylaxis, whereas 50/66 (75.8%) patients developed at least one positive HCMV DNA event after LTV prophylaxis. Of note, 25 of them (50%) experienced a clinically significant HCMV infection. The median HCMV-specific T-cell response measured against HCMV lysate but not against pp65 peptide pool was lower in patients who developed HCMV clinically significant infection after prophylaxis. A ROC analysis revealed that the level of 0.04 HCMV-specific T cells/µl should be used as cut-off for development of clinically significant HCMV reactivation after prophylaxis. CONCLUSION Assessment of HCMV-specific immunity upon discontinuation of universal prophylaxis with LTV should be considered as a method for identification of patients at risk for clinically significant HCMV infection.
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Affiliation(s)
- Federica Zavaglio
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Davide Vitello
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Federica Bergami
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Francesca Arena
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Oscar Borsani
- Department of Molecular Medicine, University of Pavia, Pavia; Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia
| | | | - Daniela Caldera
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Daniele Lilleri
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Irene Cassaniti
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia.
| | - Paolo Bernasconi
- Department of Molecular Medicine, University of Pavia, Pavia; Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia
| | - Fausto Baldanti
- Microbiology and Virology Department, Fondazione IRCCS Policlinico San Matteo, Pavia; Department of Clinical, Surgical Diagnostics and Pediatric Sciences, University of Pavia, Pavia, Italy
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Lauruschkat CD, Muchsin I, Rein A, Erhard F, Grathwohl D, Dölken L, Köchel C, Falk CS, Einsele H, Wurster S, Grigoleit GU, Kraus S. CD4+ T cells are the major predictor of HCMV control in allogeneic stem cell transplant recipients on letermovir prophylaxis. Front Immunol 2023; 14:1148841. [PMID: 37234158 PMCID: PMC10206124 DOI: 10.3389/fimmu.2023.1148841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/20/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction Human cytomegalovirus (HCMV) causes significant morbidity and mortality in allogeneic stem cell transplant (alloSCT) recipients. Recently, antiviral letermovir prophylaxis during the first 100 days after alloSCT replaced PCR-guided preemptive therapy as the primary standard of care for HCMV reactivations. Here, we compared NK-cell and T-cell reconstitution in alloSCT recipients receiving preemptive therapy or letermovir prophylaxis in order to identify potential biomarkers predicting prolonged and symptomatic HCMV reactivation. Methods To that end, the NK-cell and T-cell repertoire of alloSCT recipients managed with preemptive therapy (n=32) or letermovir prophylaxis (n=24) was characterized by flow cytometry on days +30, +60, +90 and +120 after alloSCT. Additionally, background-corrected HCMV-specific T-helper (CD4+IFNγ+) and cytotoxic (CD8+IFNγ+CD107a+) T cells were quantified after pp65 stimulation. Results Compared to preemptive therapy, letermovir prophylaxis prevented HCMV reactivation and decreased HCMV peak viral loads until days +120 and +365. Letermovir prophylaxis resulted in decreased T-cell numbers but increased NK-cell numbers. Interestingly, despite the inhibition of HCMV, we found high numbers of "memory-like" (CD56dimFcεRIγ- and/or CD159c+) NK cells and an expansion of HCMV-specific CD4+ and CD8+ T cells in letermovir recipients. We further compared immunological readouts in patients on letermovir prophylaxis with non/short-term HCMV reactivation (NSTR) and prolonged/symptomatic HCMV reactivation (long-term HCMV reactivation, LTR). Median HCMV-specific CD4+ T-cell frequencies were significantly higher in NSTR patients (day +60, 0.35 % vs. 0.00 % CD4+IFNγ+/CD4+ cells, p=0.018) than in patients with LTR, whereas patients with LTR had significantly higher median regulatory T-cell (Treg) frequencies (day +90, 2.2 % vs. 6.2 % CD4+CD25+CD127dim/CD4+ cells, p=0.019). ROC analysis confirmed low HCMV specific CD4+ (AUC on day +60: 0.813, p=0.019) and high Treg frequencies (AUC on day +90: 0.847, p=0.021) as significant predictors of prolonged and symptomatic HCMV reactivation. Discussion Taken together, letermovir prophylaxis delays HCMV reactivation and alters NK- and T-cell reconstitution. High numbers of HCMV-specific CD4+ T cells and low numbers of Tregs seem to be pivotal to suppress post-alloSCT HCMV reactivation during letermovir prophylaxis. Administration of more advanced immunoassays that include Treg signature cytokines might contribute to the identification of patients at high-risk for long-term and symptomatic HCMV reactivation who might benefit from prolonged administration of letermovir.
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Affiliation(s)
| | - Ihsan Muchsin
- Institute for Virology and Immunobiology, Julius-Maximilians-University Wuerzburg, Wuerzburg, Germany
| | - Alice Rein
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Florian Erhard
- Institute for Virology and Immunobiology, Julius-Maximilians-University Wuerzburg, Wuerzburg, Germany
| | - Denise Grathwohl
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Lars Dölken
- Institute for Virology and Immunobiology, Julius-Maximilians-University Wuerzburg, Wuerzburg, Germany
- Helmholtz-Institute for RNA-based Infection Research (HIRI), Helmholtz-Center for Infection Research (HZI), Wuerzburg, Germany
| | - Carolin Köchel
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Christine Susanne Falk
- Hannover Medical School, Institute of Transplant Immunology, Hanover, Germany
- TTU-IICH, German Center for Infection Research (DZIF), Hannover-Braunschweig, Germany
- BREATH Site, German Center for Lung Research (DZL), Hannover-Braunschweig, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - Sebastian Wurster
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Götz Ulrich Grigoleit
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
- Department of Hematology, Oncology and Immunology, Helios Hospital Duisburg, Duisburg, Germany
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Wuerzburg, Wuerzburg, Germany
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17
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Perchetti GA, Biernacki MA, Xie H, Castor J, Joncas-Schronce L, Ueda Oshima M, Kim Y, Jerome KR, Sandmaier BM, Martin PJ, Boeckh M, Greninger AL, Zamora D. Cytomegalovirus breakthrough and resistance during letermovir prophylaxis. Bone Marrow Transplant 2023; 58:430-436. [PMID: 36693927 DOI: 10.1038/s41409-023-01920-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
Letermovir is a relatively new antiviral for prophylaxis against cytomegalovirus (CMV) after allogeneic hematopoietic cell transplantation (HCT). CMV-seropositive HCT recipients who received letermovir prophylaxis from 2018 to 2020 at our center were evaluated for letermovir resistance and breakthrough CMV reactivation. Two-hundred twenty-six letermovir recipients were identified and 7/15 (47%) with CMV DNAemia ≥200 IU/mL were successfully genotyped for UL56 resistance. A single C325Y resistance mutation was identified in an umbilical cord blood recipient. Ninety-five (42%), 43 (19%), and 15 (7%) patients had breakthrough CMV at any level, ≥150 IU/mL, and ≥500 IU/mL, respectively. Risk factors for breakthrough CMV reactivation at each viral threshold were examined. Cumulative steroid exposure was the strongest risk factor for CMV at all evaluated viral thresholds. Graft-versus-host disease prophylaxis with post-transplantation cyclophosphamide (aHR 2.34, 95% CI 1.28-4.28, p = 0.001) or calcineurin inhibitors plus mycophenolate (aHR 2.24, 95% CI 1.30-3.86, p = 0.004) were also associated with an increased risk of CMV reactivation at any level. De novo letermovir resistance is rare and can be successfully treated using other antivirals. Letermovir effectively prevents clinically significant CMV, however, subclinical CMV reactivation occurs frequently at our center.
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Affiliation(s)
- Garrett A Perchetti
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Melinda A Biernacki
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Hu Xie
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jared Castor
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
| | - Laurel Joncas-Schronce
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Masumi Ueda Oshima
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
| | - YoungJun Kim
- Department of Pathology, University of Virginia, School of Medicine, Charlottesville, VA, USA
| | - Keith R Jerome
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brenda M Sandmaier
- Division of Medical Oncology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Paul J Martin
- Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine and Pathology, University of Washington, School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Danniel Zamora
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, USA.
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18
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Giménez E, Guerreiro M, Torres I, Aguilar C, Albert E, Hernández-Boluda JC, Hernani R, Pérez A, Amat P, Piñana JL, Montoro J, Solano C, Navarro D. Features of cytomegalovirus DNAemia and virus-specific T-cell responses in allogeneic hematopoietic stem-cell transplant recipients during prophylaxis with letermovir. Transpl Infect Dis 2023; 25:e14021. [PMID: 36748748 DOI: 10.1111/tid.14021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is scarce information on the natural kinetics of cytomegalovirus (CMV) DNAemia and dynamics of CMV-specific T-cell reconstitution in allogeneic hematopoietic transplant recipients (allo-HSCT) undergoing letermovir (LMV) prophylaxis. METHODS Twelve adult CMV-seropositive high-risk recipients (median age, 53 years; 9 males/3 females) undergoing LMV prophylaxis and 13 non-LMV allo-HSCT controls (median age, 58 years; 7 males/6 females) were included. CMV DNAemia in plasma was monitored by real-time polymerase chain reaction. Preemptive antiviral therapy (PET) was administered upon detection of ≥1500 IU/ml. CMV-specific interferon-gamma (IFN-γ)-producing CD8+ and CD4+ T cells were enumerated by flow cytometry around days +30, +60, and +90 after allo-HSCT. Ex vivo experiments assessing of the potential effect of LMV on CMV-specific T-cell expansion in a single CMV-seropositive donor were also conducted. RESULTS Five LMV patients (41.6%) developed CMV DNAemia that cleared spontaneously. Four patients (33.3%) developed CMV DNAemia after LMV cessation, of which two required PET. Nine non-LMV patients (69.2%) developed CMV DNAemia (five required PET). The percentage of LMV and non-LMV patients exhibiting detectable CMV-specific T-cell responses was comparable (7/10 vs. 10/13; p = .71). Nevertheless, median CMV-specific CD4+ and CD8+ T-cell counts were lower in LMV patients by days +60 (p = .006 and .02, respectively) and +90 (p = .08 and .02). Ex vivo, CMV-specific CD8+ T cells expanded to the same level either in the presence (19.8%) or in the absence of LMV (20.6%). CONCLUSIONS In our series, episodes of CMV DNAemia in LMV patients cleared spontaneously. A diminished degree of CMV-specific T-cell reconstitution in LMV patients compared to non-LMV patients was observed.
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Affiliation(s)
- Estela Giménez
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Guerreiro
- Hematology Service, Hospital Universitario y Politécnico "La Fe", Valencia, Spain
| | - Ignacio Torres
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Cristobal Aguilar
- Hematology Service, Hospital Universitario y Politécnico "La Fe", Valencia, Spain
| | - Eliseo Albert
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Juan Carlos Hernández-Boluda
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Rafael Hernani
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Ariadna Pérez
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Paula Amat
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - José Luis Piñana
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain
| | - Juan Montoro
- Hematology Service, Hospital Universitario y Politécnico "La Fe", Valencia, Spain
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, INCLIVA Health Research Institute, Valencia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.,Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
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19
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Khawaja F, Spallone A, Kotton CN, Chemaly RF. Cytomegalovirus infection in transplant recipients: newly approved additions to our armamentarium. Clin Microbiol Infect 2023; 29:44-50. [PMID: 35843567 DOI: 10.1016/j.cmi.2022.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/01/2022] [Accepted: 07/02/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND The burden that cytomegalovirus (CMV) portends for haematopoietic and solid-organ transplant recipients cannot be understated. Valganciclovir and ganciclovir have successfully been used for prevention and treatment of CMV infections, although with serious side effects such as leucopenia and some development of resistance. Until recently, available therapies for ganciclovir-resistant CMV have significant toxicities. Although advances have been made in the field, the unmet medical needs for effective and well-tolerated therapies are significant. OBJECTIVES This review aims to summarise the current and emerging CMV antiviral drugs and discusses future perspectives in the field. SOURCES We searched for relevant articles with pertinent keywords: "Cytomegalovirus OR CMV", "Transplant" and "Antiviral". Articles published after 2019 were given preference. Articles were reviewed by the authors for relevance and impact to the subject of interest. CONTENT We outline in this review current advances in prophylaxis of CMV infection with letermovir, breakthrough CMV infections while on or after prophylaxis, the development of resistant and refractory CMV infections, and the newly approved anti-CMV agent, maribavir, in haematopoietic and solid-organ transplant recipients. IMPLICATIONS Prevention of CMV infections after transplant has improved greatly over the past few years. Despite major advancements, breakthrough CMV infections and development of refractory and resistant CMV infections remain major complications post transplantation. We highlight emerging therapeutics that tolerably and effectively prevent and treat CMV infections, especially refractory and resistant cases.
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Affiliation(s)
- Fareed Khawaja
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Spallone
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Camille N Kotton
- Transplant Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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20
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Kotton CN, Torre-Cisneros J, Aguado JM, Alain S, Baldanti F, Baumann G, Boeken U, de la Calle M, Carbone J, Ciceri F, Comoli P, Couzi L, Danziger-Isakov L, Fernández-Ruiz M, Girmenia C, Grossi PA, Hirsch HH, Humar A, Kamar N, Kotton C, Ljungman P, Malagola M, Mira E, Mueller N, Sester M, Teng CLJ, Torre-Cisneros J, Ussetti P, Westall G, Wolf D, Zamora M. Cytomegalovirus in the transplant setting: Where are we now and what happens next? A report from the International CMV Symposium 2021. Transpl Infect Dis 2022; 24:e13977. [PMID: 36271650 PMCID: PMC10078482 DOI: 10.1111/tid.13977] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/16/2022] [Accepted: 09/27/2022] [Indexed: 12/24/2022]
Abstract
The CMV Symposium in September 2021 was an international conference dedicated to cytomegalovirus (CMV) infection after solid organ or hematopoietic stem cell transplantation. This review provides an overview of the presentations given by the expert faculty, supplemented with educational clinical cases. Topics discussed include CMV epidemiology and diagnosis, the burden of CMV infection and disease, CMV-specific immunity and management of CMV in transplant settings. Major advances in the prevention and treatment of CMV in the past decade and increased understanding of CMV immunity have led to improved patient outcomes. In the future, management algorithms may be individualized based on the transplant recipient's immune profile, which will mark the start of a new era for patients with CMV.
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Affiliation(s)
- Camille N Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julián Torre-Cisneros
- Maimónides Institute for Biomedical Research of Cordoba (IMIBIC)/Reina Sofía University Hospital/University of Cordoba (UCO), Cordoba, Spain.,CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | | | - José Maria Aguado
- University Hospital 12 de Octubre, CIBERINFEC, ISCIII - CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Sophie Alain
- French References Center for Herpes Viruses, Microbiology Department, CHU-Limoges, Limoges, France
| | - Fausto Baldanti
- Università di Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany
| | | | - Javier Carbone
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Fabio Ciceri
- IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milan, Italy
| | - Patrizia Comoli
- Cell Factory and Center for Advanced Therapies and Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lionel Couzi
- Department of Nephrology, Transplantation, Dialysis and Apheresis, CHU Bordeaux CNRS-UMR 5164 ImmunoConcEpT, Bordeaux University, Bordeaux, France
| | - Lara Danziger-Isakov
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, USA
| | | | | | | | | | | | | | | | - Per Ljungman
- Karolinska Hospital and Karolinska Institute, Stockholm, Sweden
| | | | | | | | | | | | | | | | | | - Dana Wolf
- Hadassah University Medical Center, Jerusalem, Israel
| | - Marty Zamora
- University of Colorado at Denver Anschutz Medical Center, Colorado, USA
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21
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Cui J, Zhao K, Sun Y, Wen R, Zhang X, Li X, Long B. Diagnosis and treatment for the early stage of cytomegalovirus infection during hematopoietic stem cell transplantation. Front Immunol 2022; 13:971156. [PMID: 36211358 PMCID: PMC9537469 DOI: 10.3389/fimmu.2022.971156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Cytomegalovirus (CMV) infection remains a frequent complication after hematopoietic stem cell transplantation (HSCT) and causes significant morbidity and mortality in transplantation recipients. In this review, we highlight the role of major risk factors that are associated with the incidence of CMV infection. Advances in immunosurveillance may predict CMV infection, allowing early interventions to prevent severe infection. Furthermore, numerous therapeutic strategies against CMV infection after HSCT are summarized. A comprehensive understanding of the current situation of CMV treatment may provide a hint for clinical practice and even promote the development of novel strategies for precision medicine.
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Affiliation(s)
| | | | | | | | | | - Xudong Li
- *Correspondence: Bing Long, longb3@ mail.sysu.edu.cn; Xudong Li,
| | - Bing Long
- *Correspondence: Bing Long, longb3@ mail.sysu.edu.cn; Xudong Li,
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22
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Royston L, Masouridi-Levrat S, Gotta V, Royston E, Pressacco-Brossier C, Abi Aad Y, Tonoli D, Karmime A, Jayo M, Van Delden C, Lescuyer P, Pfister M, Chalandon Y, Neofytos D. Therapeutic Drug Monitoring of Orally Administered Letermovir Prophylaxis in Allogeneic Hematopoietic Stem Cell Transplant Recipients. Antimicrob Agents Chemother 2022;:e0065722. [PMID: 35876579 DOI: 10.1128/aac.00657-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
With balanced safety-efficacy profile, letermovir anti-cytomegalovirus (CMV) prophylaxis is used in hematopoietic stem cell transplant recipients (HSCTR). We assessed feasibility and usefulness of letermovir therapeutic drug monitoring (TDM) in HSCTR. We performed a prospective observational study on letermovir-TDM including 40 consecutive adult CMV-seropositive allogeneic-HSCTR who received orally (PO) administered letermovir. Minimal blood concentrations of letermovir (Ctrough) were measured on days 3 and 7 postletermovir initiation and weekly thereafter. Letermovir-Ctrough remained stable during the first 70 days post-HSCT at a median of 286 μg/L (interquartile range, 131 to 591 μg/L), with large interpatient/intrapatient variability. No associations between breakthrough clinically significant CMV infection or detectable CMV DNAemia and letermovir-Ctrough were observed. Patients with letermovir-associated adverse events had higher letermovir-Ctrough than patients without (400 versus 266 μg/L, P = 0.02). Letermovir-Ctrough was similar in patients with or without gastrointestinal symptoms (280 versus 300 μg/L, P = 0.49). Acute grade ≥2 GvHD was associated with higher letermovir-Ctrough (479 versus 248 μg/L, P = 0.001), including gastrointestinal GvHD (499 versus 263 μg/L, P = 0.004). Concomitantly administered posaconazole and cyclosporine were associated with higher letermovir-Ctrough (707 versus 259 μg/L, P < 0.001 and 437 versus 248 μg/L, P = 0.01, respectively). In multivariable analysis, both posaconazole (odds ratio [OR], 4.9; 95% confidence interval [CI], 2.4 to 9.7; P < 0.0001) and cyclosporine-adjusted letermovir dose at 240 mg daily (OR, 3.5; 95% CI, 1.4 to 9.0; P = 0.01) were independently associated with higher letermovir-Ctrough. In conclusion, administration of PO letermovir led to measurable and relatively stable letermovir-Ctrough, without noticeable associations with clinical efficacy. Letermovir exposure was not affected by gastrointestinal symptoms, but with posaconazole and cyclosporine administration. Associations between letermovir and concomitantly administered agents and adverse events warrant additional clinical studies.
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23
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Politikos I, Lau C, Devlin SM, Quach S, Lin A, Perales MA, Shah GL, Seo SK, Papanicolaou GA, Barker JN. Extended-duration letermovir prophylaxis for cytomegalovirus infection after cord blood transplantation in adults. Blood Adv 2022; 6:6291-300. [PMID: 35802462 DOI: 10.1182/bloodadvances.2022008047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 01/07/2023] Open
Abstract
Cord blood transplantation (CBT) can be complicated by a high incidence of clinically significant cytomegalovirus infection (csCMVi). We have investigated the efficacy of extended letermovir prophylaxis in seropositive adult CBT recipients. The aim was to continue prophylaxis for ≥6 months (insurance permitting). By day 100, the incidence of csCMVi was 0% in 28 patients who received letermovir prophylaxis. Moreover, of 24 patients alive at day 100, none had csCMVi by day 180, having continued prophylaxis for all (n = 20) or part (n = 4) of that period. Overall, 20 patients stopped letermovir at a median of 354 days (range, 119-455 days) posttransplant, with only 5 requiring 1 (n = 4) or 2 (n = 1) courses of valganciclovir (median total duration, 58 days; range, 12-67 days) for postprophylaxis viremia, with no subsequent csCMVi. There were no toxicities attributable to letermovir. Of the 62 historic control subjects who received acyclovir only, 51 developed csCMVi (median onset, 34 days; range, 5-74 days), for a day 100 incidence of 82% (95% confidence interval, 73-92). Seven patients developed proven/probable CMV disease, and 6 died before day 100 (3 with proven/probable CMV pneumonia). Forty-five patients required extended therapy during the first 6 months for 1 (n = 10), 2 (n = 14), or 3/persistent (n = 21) csCMVi, with 43 (84%) of 51 developing significant treatment toxicities. Letermovir is a highly effective, well-tolerated prophylaxis that mitigates CMV infection, CMV-related mortality, and antiviral therapy toxicities in CBT recipients. Our data support prophylaxis duration of at least 6 months after CBT.
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24
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Nguyen A, Finci L, Berney T, Tonoli D, Lescuyer P, Jayo M, Brossier Pressacco C, van Delden C, Neofytos D. Letermovir for cytomegalovirus primary prophylaxis in a multiple abdominal/small bowel transplant recipient. Clin Transplant 2022; 36:e14624. [PMID: 35235221 DOI: 10.1111/ctr.14624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Aude Nguyen
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Leon Finci
- Service de Transplantation Chirurgicale, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Thierry Berney
- Service de Transplantation Chirurgicale, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - David Tonoli
- Service de Toxicologie, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Pierre Lescuyer
- Service de Toxicologie, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Murielle Jayo
- Service de Toxicologie, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | | | - Christian van Delden
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Genève, Switzerland
| | - Dionysios Neofytos
- Service des Maladies Infectieuses, Hôpitaux Universitaires de Genève, Genève, Switzerland
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25
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Freyer CW, Carulli A, Gier S, Ganetsky A, Timlin C, Schuster M, Babushok D, Frey NV, Gill SI, Hexner EO, Luger SM, Mangan JK, Martin ME, McCurdy SR, Perl AE, Porter DL, Pratz K, Smith J, Stadtmauer EA, Loren AW. Letermovir vs. high-dose valacyclovir for cytomegalovirus prophylaxis following haploidentical or mismatched unrelated donor allogeneic hematopoietic cell transplantation receiving post-transplant cyclophosphamide. Leuk Lymphoma 2022; 63:1925-1933. [PMID: 35188052 DOI: 10.1080/10428194.2022.2042686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients undergoing haploidentical or mismatched unrelated donor (haplo/MMUD) allogeneic hematopoietic cell transplantation (alloHCT) receiving post-transplant cyclophosphamide (PTCy) are at high risk of cytomegalovirus (CMV) infection. Experience with letermovir (LET) in this population is limited. This single center retrospective cohort study compared CMV and transplant outcomes between LET and a historical control with high-dose valacyclovir (HDV) prophylaxis in adults undergoing haplo/MMUD alloHCT. Thirty-eight CMV seropositive patients were included, 19 in each arm. LET reduced the incidence of CMV infection (5% vs. 53%, RR 0.01, 95% CI 0.014-0.71, p = .001) and need for CMV treatment by day +100 (5% vs. 37%, RR 0.14, 95% CI 0.18-0.99, p = .017) compared to HDV. Median CMV event-free-survival was improved with LET (not reached vs. 80 days, HR 0.114, 95% CI 0.07-0.61, p = .004). These data support the efficacy of LET in alternative donor transplants.
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Affiliation(s)
- Craig W Freyer
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alison Carulli
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon Gier
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alex Ganetsky
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Timlin
- Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mindy Schuster
- Infectious Diseases Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Daria Babushok
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Noelle V Frey
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Saar I Gill
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Elizabeth O Hexner
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Selina M Luger
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - James K Mangan
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Mary Ellen Martin
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Shannon R McCurdy
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alexander E Perl
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - David L Porter
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Keith Pratz
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Jacqueline Smith
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Edward A Stadtmauer
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
| | - Alison W Loren
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Abramson Cancer Center and the Division of Hematology and Oncology, Philadelphia, PA, USA
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26
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Gabanti E, Borsani O, Colombo AA, Zavaglio F, Binaschi L, Caldera D, Sciarra R, Cassinelli G, Alessandrino EP, Bernasconi P, Ferretti VV, Lilleri D, Baldanti F. Human cytomegalovirus-specific T-cell reconstitution and late-onset cytomegalovirus infection in hematopoietic stem cell transplant recipients following letermovir prophylaxis. Transplant Cell Ther 2022; 28:211.e1-211.e9. [PMID: 35042012 DOI: 10.1016/j.jtct.2022.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/28/2021] [Accepted: 01/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Letermovir (LTV), recently approved for the prophylaxis of human Citomegalovirus (HCMV) reactivation after hematopoietic stem cell transplantation (HSCT), has decreased the rate of infection in the first months post-transplant. OBJECTIVE The aim of this study was to evaluate the impact of LTV prophylaxis on immune reconstitution and late-onset infection. STUDY DESIGN We studied HCMV infection and HCMV-specific T-cell reconstitution in two matched groups of HSCT recipients receiving LTV prophylaxis (N=30, LTV group) vs pre-emptive therapy (N=31, PET group). Rate of GvHD, neutropenia, baseline disease recurrence and overall survival were analyzed. RESULTS Clinically significant infections requiring pre-emptive therapy showed a similar rate in the PET (21/31, 68%) vs the LTV group (17/30, 57%; P=0.434), but occurred significantly later (after prophylaxis discontinuation) in the LTV group. No difference was found in peak HCMV DNAemia levels (P=0.232). HCMV-specific T-cell recovery was delayed by about 100 days in the LTV group. HCMV-specific CD4 and CD8 T cells were significantly lower in the LTV group between days 120-360 and 90-120, respectively. A lower rate of chronic GvHD (P=0.024) was found in the LTV-group. Time to engraftment, rate of disease relapse and one-year survival were not different in the two groups, whereas a trend towards a lower occurrence of neutropenia (P=0.124) and higher occurrence of acute GvHD grade III-IV (P=0.103) was observed in the LTV group. CONCLUSIONS LTV prophylaxis delays HCMV infection and HCMV-specific immune reconstitution, therefore immunological and virological monitoring should be implemented post-prophylaxis discontinuation. The potential effect of LTV prophylaxis in reducing chronic GvHD should be evaluated by prospective studies.
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Affiliation(s)
- Elisa Gabanti
- Microbiology and Virology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Oscar Borsani
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - Anna Amelia Colombo
- Hematology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federica Zavaglio
- Microbiology and Virology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luana Binaschi
- Microbiology and Virology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Daniela Caldera
- Hematology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberta Sciarra
- Hematology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | - Paolo Bernasconi
- Hematology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Daniele Lilleri
- Microbiology and Virology Unit, IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Fausto Baldanti
- Microbiology and Virology Unit, IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia Italy
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27
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Abu-Omar A, Sester M. Ways to boost cellular immunity in solid organ transplant recipients - the case of letermovir. Transpl Infect Dis 2022; 24:e13787. [PMID: 34989470 DOI: 10.1111/tid.13787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 12/27/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Amina Abu-Omar
- Department of Transplant and Infection Immunology, Saarland University, Homburg, 66421, Germany
| | - Martina Sester
- Department of Transplant and Infection Immunology, Saarland University, Homburg, 66421, Germany
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Xue E, Lorentino F, Clerici D, Farina F, Oltolini C, Giglio F, Campodonico E, Nitti R, Bernardi M, Corti C, Peccatori J, Ciceri F, Lupo Stanghellini MT, Greco R. Coadministration of letermovir and sirolimus in allogeneic hematopoietic cell transplant recipients. Bone Marrow Transplant 2022; 57:128-130. [PMID: 34625664 DOI: 10.1038/s41409-021-01486-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/12/2021] [Accepted: 09/27/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Elisabetta Xue
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Lorentino
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,PhD Program in Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Daniela Clerici
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Farina
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chiara Oltolini
- Clinic of Infectious Diseases, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Giglio
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Campodonico
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
| | - Rosamaria Nitti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
| | - Massimo Bernardi
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Consuelo Corti
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,University Vita-Salute San Raffaele, Milan, Italy
| | | | - Raffaella Greco
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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29
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Martino M, Pitino A, Gori M, Bruno B, Crescimanno A, Federico V, Picardi A, Tringali S, Ingrosso C, Carluccio P, Pastore D, Musuraca G, Paviglianiti A, Vacca A, Serio B, Storti G, Mordini N, Leotta S, Cimminiello M, Prezioso L, Loteta B, Ferreri A, Colasante F, Merla E, Giaccone L, Busca A, Musso M, Scalone R, Di Renzo N, Marotta S, Mazza P, Musto P, Attolico I, Selleri C, Canale FA, Pugliese M, Tripepi G, Porto G, Martinelli G, Carella AM, Cerchione C. Letermovir Prophylaxis for Cytomegalovirus Infection in Allogeneic Stem Cell Transplantation: A Real-World Experience. Front Oncol 2021; 11:740079. [PMID: 34616684 PMCID: PMC8489185 DOI: 10.3389/fonc.2021.740079] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022] Open
Abstract
Despite effective treatments, cytomegalovirus (CMV) continues to have a significant impact on morbidity and mortality in allogeneic stem cell transplant (allo-SCT) recipients. This multicenter, retrospective, cohort study aimed to evaluate the reproducibility of the safety and efficacy of commercially available letermovir for CMV prophylaxis in a real-world setting. Endpoints were rates of clinically significant CMV infection (CSCI), defined as CMV disease or CMV viremia reactivation within day +100-+168. 204 adult CMV-seropositive allo-SCT recipients from 17 Italian centres (median age 52 years) were treated with LET 240 mg/day between day 0 and day +28. Overall, 28.9% of patients underwent a haploidentical, 32.4% a matched related, and 27.5% a matched unrelated donor (MUD) transplant. 65.7% were considered at high risk of CSCI and 65.2% had a CMV seropositive donor. Low to mild severe adverse events were observed in 40.7% of patients during treatment [gastrointestinal toxicity (36.3%) and skin rash (10.3%)]. Cumulative incidence of CSCI at day +100 and day +168 was 5.4% and 18.1%, respectively, whereas the Kaplan-Meier event rate was 5.8% (95% CI: 2.4-9.1) and 23.3% (95% CI: 16.3-29.7), respectively. Overall mortality was 6.4% at day +100 and 7.3% at day +168. This real-world experience confirms the efficacy and safety of CMV.
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Affiliation(s)
- Massimo Martino
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Annalisa Pitino
- Istituto di Fisiologia Clinica del Consiglio Nazionale delle Ricerche (CNR), Roma, Italy
| | - Mercedes Gori
- Istituto di Fisiologia Clinica del Consiglio Nazionale delle Ricerche (CNR), Roma, Italy
| | - Benedetto Bruno
- Dipartimento di Oncologia, SSD Trapianto Allogenico di Cellule Staminali, AOU Città della Salute e della Scienza di Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, Divisione di Ematologia, Università di Torino, Torino, Italy
| | | | - Vincenzo Federico
- Ematologia e Trapianto di Cellule Staminali, Polo Ospedaliero "Vito Fazzi", Lecce, Italy
| | - Alessandra Picardi
- UOC Ematologia con Trapianto CSE, AORN "Antonio Cardarelli", Napoli, Italy.,Dipartimento di Biomedicina e Prevenzione, Università di Roma Tor Vergata, Roma, Italy
| | | | - Claudia Ingrosso
- Ematologia e Trapianto di Midollo Osseo, Ospedale "San Giuseppe Moscati", Taranto, Italy
| | - Paola Carluccio
- UOC di Ematologia con Trapianto, Dipartimento di Emergenza e Trapianti d'Organo, Università degli Studi "Aldo Moro" e AOUC Policlinico di Bari, Bari, Italy
| | - Domenico Pastore
- Divisione di Ematologia, Ospedale "Antonio Perrino", Brindisi, Italy
| | - Gerardo Musuraca
- Unità di Ematologia, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Annalisa Paviglianiti
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Adriana Vacca
- UO Ematologia - CTMO, Polo Ospedaliero "Armando Businco", Cagliari, Italy
| | - Bianca Serio
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Università di Salerno, Salerno, Italy
| | - Gabriella Storti
- Unità di Ematologia, Azienda Ospedaliera "San Giuseppe Moscati", Avellino, Italy
| | - Nicola Mordini
- SC Ematologia, Azienda Ospedaliera "S. Croce e Carle", Cuneo, Italy
| | - Salvatore Leotta
- Programma di Trapianto Emopoietico, Azienda Policlinico "Vittorio Emanuele", Catania, Italy
| | | | - Lucia Prezioso
- Ematologia e Centro Trapianti Midollo Osseo (CTMO), Dipartimento ad Attività Integrata Medicina Generale e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Barbara Loteta
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Anna Ferreri
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Fabrizia Colasante
- Ospedale I.R.C.C.S. Casa Sollievo della Sofferenza - Centro Trapianti di Cellule Staminali, San Giovanni Rotondo, Italy
| | - Emanuela Merla
- Ospedale I.R.C.C.S. Casa Sollievo della Sofferenza - Centro Trapianti di Cellule Staminali, San Giovanni Rotondo, Italy
| | - Luisa Giaccone
- Dipartimento di Oncologia, SSD Trapianto Allogenico di Cellule Staminali, AOU Città della Salute e della Scienza di Torino, Torino, Italy.,Dipartimento di Biotecnologie Molecolari e Scienze per la Salute, Divisione di Ematologia, Università di Torino, Torino, Italy
| | - Alessandro Busca
- Dipartimento di Oncologia, SSD Trapianto Allogenico di Cellule Staminali, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Maurizio Musso
- Unità Operativa di Oncoematologia e TMO, Istituto "La Maddalena", Palermo, Italy
| | - Renato Scalone
- Unità Operativa di Oncoematologia e TMO, Istituto "La Maddalena", Palermo, Italy
| | - Nicola Di Renzo
- Ematologia e Trapianto di Cellule Staminali, Polo Ospedaliero "Vito Fazzi", Lecce, Italy
| | - Serena Marotta
- UOC Ematologia con Trapianto CSE, AORN "Antonio Cardarelli", Napoli, Italy
| | - Patrizio Mazza
- Ematologia e Trapianto di Midollo Osseo, Ospedale "San Giuseppe Moscati", Taranto, Italy
| | - Pellegrino Musto
- UOC di Ematologia con Trapianto, Dipartimento di Emergenza e Trapianti d'Organo, Università degli Studi "Aldo Moro" e AOUC Policlinico di Bari, Bari, Italy
| | - Immacolata Attolico
- UOC di Ematologia con Trapianto, Dipartimento di Emergenza e Trapianti d'Organo, Università degli Studi "Aldo Moro" e AOUC Policlinico di Bari, Bari, Italy
| | - Carmine Selleri
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Università di Salerno, Salerno, Italy
| | - Filippo Antonio Canale
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Marta Pugliese
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Giovanni Tripepi
- Istituto di Fisiologia Clinica del Consiglio Nazionale delle Ricerche (CNR), Reggio Calabria, Italy
| | - Gaetana Porto
- Centro Unico Regionale Trapianti Cellule Staminali e Terapie Cellulari (CTMO), Grande Ospedale Metropolitano "Bianchi-Melacrino-Morelli", Reggio Calabria, Italy
| | - Giovanni Martinelli
- Unità di Ematologia, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Angelo Michele Carella
- Ospedale I.R.C.C.S. Casa Sollievo della Sofferenza - Centro Trapianti di Cellule Staminali, San Giovanni Rotondo, Italy
| | - Claudio Cerchione
- Unità di Ematologia, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
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30
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Hakki M, Aitken SL, Danziger-Isakov L, Michaels MG, Carpenter PA, Chemaly RF, Papanicolaou GA, Boeckh M, Marty FM. American Society for Transplantation and Cellular Therapy Series: #3-Prevention of Cytomegalovirus Infection and Disease After Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:707-719. [PMID: 34452721 DOI: 10.1016/j.jtct.2021.05.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/02/2021] [Indexed: 11/20/2022]
Abstract
The Practice Guidelines Committee of the American Society for Transplantation and Cellular Therapy partnered with its Transplant Infectious Disease Special Interest Group to update its 2009 compendium-style infectious diseases guidelines for the care of hematopoietic cell transplant (HCT) recipients. A new approach was taken with the goal of better serving clinical providers by publishing each standalone topic in the infectious disease series as a concise format of frequently asked questions (FAQ), tables, and figures. Adult and pediatric infectious disease and HCT content experts developed and answered FAQs. Topics were finalized with harmonized recommendations that were made by assigning an A through E strength of recommendation paired with a level of supporting evidence graded I through III. The third topic in the series focuses on the prevention of cytomegalovirus infection and disease in HCT recipients by reviewing prophylaxis and preemptive therapy approaches; key definitions, relevant risk factors, and diagnostic monitoring considerations are also reviewed.
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Affiliation(s)
- Morgan Hakki
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon.
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lara Danziger-Isakov
- Division of Infectious Disease, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Marian G Michaels
- Division of Pediatric Infectious Diseases, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and the University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, & Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Michael Boeckh
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Vaccine and Infectious Disease Divisions, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Francisco M Marty
- Division of Infectious Diseases, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
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31
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Royston L, Royston E, Masouridi-Levrat S, Chalandon Y, Van Delden C, Neofytos D. Predictors of breakthrough clinically significant cytomegalovirus infection during letermovir prophylaxis in high-risk hematopoietic cell transplant recipients. Immun Inflamm Dis 2021; 9:771-776. [PMID: 33949798 PMCID: PMC8342239 DOI: 10.1002/iid3.431] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 01/16/2023]
Abstract
Letermovir prophylaxis in allogeneic hematopoietic cell transplant recipients significantly reduces the incidence of clinically significant cytomegalovirus infection. However, breakthrough infections still occur despite adequate prophylaxis. In the present retrospective cohort study, we identified clinically relevant predictive factors for clinically significant CMV breakthrough infection during letermovir prophylaxis. Low‐grade CMV replication (21–149 IU/ml), both at the time of letermovir initiation or during prophylaxis, was a significant risk factor for breakthrough clinically significant CMV infection. In addition, development of acute gastrointestinal graft‐versus‐host disease was significantly associated with breakthrough infection. Altogether these findings could call clinicians' attention to closer CMV monitoring and allow for prompt preemptive treatment initiation.
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Affiliation(s)
- Léna Royston
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Eva Royston
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva, Geneva, Switzerland
| | | | - Yves Chalandon
- Division of Hematology, Bone Marrow Transplant Unit, University Hospital of Geneva, Geneva, Switzerland
| | - Christian Van Delden
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, University Hospital of Geneva, Geneva, Switzerland
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Singha A, Burcham PK, Logan A, El Boghdadly Z, Howsare MM, Nunley DR, Lustberg ME, Keller BC. Letermovir for Cytomegalovirus Prophylaxis in Lung Transplant Patients with Valganciclovir-Induced Leukopenia. Transplantology 2021; 2:129-39. [DOI: 10.3390/transplantology2020013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cytomegalovirus (CMV) prophylaxis with valganciclovir is the standard of practice in most transplant centers, but treatment-related leukopenia can limit valganciclovir’s use. Therefore, we evaluated letermovir, a novel antiviral agent recently approved for use in hematopoietic cell transplant patients as CMV prophylaxis, in lung transplant recipients unable to tolerate valganciclovir due to severe leukopenia. We performed a retrospective analysis of all lung transplant patients at our center who received letermovir for CMV prophylaxis between 1 December 2018 and 1 January 2020. A repeated measures mixed model was used to analyze white blood cell (WBC) trends, and descriptive statistics were used to analyze secondary endpoints, including CMV DNAemia, renal function, immunosuppression dosing, and allograft function. Seventeen patients were administered letermovir during the study period due to valganciclovir-induced leukopenia (median WBC nadir 1.1 K/uL, range <0.30–2.19 K/uL). Median WBC improvement was noted in 15 (88.2%) patients after starting letermovir. Breakthrough CMV DNAemia necessitating treatment occurred in two patients, with one of the two cases being due to patient noncompliance. CMV resistance to letermovir was detected in two patients, necessitating a change to an alternative agent in one of these patients. No major side effects were reported in any patient. Letermovir is a generally safe and effective alternative for CMV prophylaxis in lung transplant recipients unable to tolerate valganciclovir due to leukopenia.
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Chiereghin A, Belotti T, Borgatti EC, Fraccascia N, Piccirilli G, Fois M, Borghi M, Turello G, Gabrielli L, Masetti R, Prete A, Fanti S, Lazzarotto T. Off-Label Use of Letermovir as Preemptive Anti-Cytomegalovirus Therapy in a Pediatric Allogeneic Peripheral Blood Stem Cell Transplant. Infect Drug Resist 2021; 14:1185-1190. [PMID: 33790588 PMCID: PMC8001039 DOI: 10.2147/idr.s296927] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/19/2021] [Indexed: 12/14/2022] Open
Abstract
Despite the effectiveness of the currently available antiviral drugs in treating cytomegalovirus (CMV) infection, high rates of adverse effects are associated with their use. Moreover, a problem of increasing importance is the emergence of drug-resistant CMV infection. Here, we describe the first case of off-label use of letermovir (LMV) as preemptive antiviral therapy, in a pediatric allogeneic peripheral blood stem cell transplant recipient with ganciclovir-resistant CMV infection who was intolerant to foscarnet and unable to achieve viral clearance after seven doses of cidofovir. After the administration of LMV, a gradual reduction in viral load was observed and within 6 weeks of LMV treatment, after more than 6 months of positive CMV-DNAemia, the patient cleared the infection. No adverse effects associated with LMV were observed during treatment. In this pediatric study case, the off-label use of LMV for the treatment of CMV infection has been well tolerated and proved to be effective in leading to the suppression of viral replication.
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Affiliation(s)
- Angela Chiereghin
- Section of Microbiology, Department of Specialized, Experimental, and Diagnostic Medicine, University of Bologna, Bologna, Italy.,Department of Public Health, Local Health Authority of Bologna, Bologna, Italy
| | - Tamara Belotti
- Pediatric Oncology and Haematology Unit "Lalla Seragnoli", Department of Pediatrics, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Eva Caterina Borgatti
- Microbiology Unit, Department of Specialized, Experimental, and Diagnostic Medicine, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Nicola Fraccascia
- Nuclear Medicine Unit, Department of Specialized, Experimental, and Diagnostic Medicine, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Giulia Piccirilli
- Microbiology Unit, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Maura Fois
- Pediatric Oncology and Haematology Unit "Lalla Seragnoli", Department of Pediatrics, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Michele Borghi
- Microbiology Unit, Department of Specialized, Experimental, and Diagnostic Medicine, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Gabriele Turello
- Microbiology Unit, Department of Specialized, Experimental, and Diagnostic Medicine, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Liliana Gabrielli
- Microbiology Unit, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Riccardo Masetti
- Pediatric Oncology and Haematology Unit "Lalla Seragnoli", Department of Pediatrics, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Arcangelo Prete
- Pediatric Oncology and Haematology Unit "Lalla Seragnoli", Department of Pediatrics, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Stefano Fanti
- Nuclear Medicine Unit, Department of Specialized, Experimental, and Diagnostic Medicine, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
| | - Tiziana Lazzarotto
- Microbiology Unit, Department of Specialized, Experimental, and Diagnostic Medicine, IRCCS St. Orsola Polyclinic, University of Bologna, Bologna, Italy
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