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Zaffiri L, Chambers ET. Screening and Management of PTLD. Transplantation 2023; 107:2316-2328. [PMID: 36949032 DOI: 10.1097/tp.0000000000004577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
Posttransplant lymphoproliferative disorder (PTLD) represents a heterogeneous group of lymphoproliferative diseases occurring in the setting of immunosuppression following hematopoietic stem cells transplant and solid organ transplantation. Despite its overall low incidence, PTLD is a serious complication following transplantation, with a mortality rate as high as 50% in transplant recipients. Therefore, it is important to establish for each transplant recipient a personalized risk evaluation for the development of PTLD based on the determination of Epstein-Barr virus serostatus and viral load following the initiation of immunosuppression. Due to the dynamic progression of PTLD, reflected in the diverse pathological features, different therapeutic approaches have been used to treat this disorder. Moreover, new therapeutic strategies based on the administration of virus-specific cytotoxic T cells have been developed. In this review, we summarize the available data on screening and treatment to suggest a strategy to identify transplant recipients at a higher risk for PTLD development and to review the current therapeutic options for PTLD.
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Affiliation(s)
- Lorenzo Zaffiri
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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2
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He H, Lei F, Huang L, Wang K, Yang Y, Chen L, Peng Y, Liang Y, Tan H, Wu X, Feng M. Immunotherapy of Epstein-Barr virus (EBV) infection and EBV-associated hematological diseases with gp350/CD89-targeted bispecific antibody. Biomed Pharmacother 2023; 163:114797. [PMID: 37126928 DOI: 10.1016/j.biopha.2023.114797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/17/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023] Open
Abstract
Acute and persistent infection of Epstein-Barr virus (EBV) is associated with several life-threatening hematological disorders, including lymphoproliferative disorders (LPD), hemophagocytic lymphohistiocytosis (HLH), and chronic active Epstein-Barr virus infection (CAEBV). Currently, there are no efficacious virus-targeted therapies for EBV-driven hematological diseases. To explore the potential of phagocytosis-based immunotherapy, we created a bispecific antibody by targeting the viral envelope protein gp350 with a novel EBV-neutralizing antibody (named R1) that was paired with a monoclonal antibody against CD89 for redirecting macrophages and neutrophils. In vitro study showed that the bispecific antibody enabled efficient phagocytosis of EBV and killing of gp350 + lymphoma cells in the presence of PBMC. In vivo studies in NSG mice inoculated with EBV showed that bispecific antibody dramatically reduced the viral load in blood, solid organs and tissues. Treatment of mice implanted with EBV-harboring Raji lymphoma cells efficiently prevented tumor formation and massive metastasis to solid organs. Treatment of mice implanted with whole blood from EBV-HLH patients was effective in reducing viral levels in blood and solid organ. The gp350/CD89 bispecific antibody was highly effective in clearing EBV and immunotherapy of EBV-driven hematological diseases such as LPD and EBV-HLH.
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Affiliation(s)
- Huixia He
- College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Feifei Lei
- Department of Infectious Diseases, Lab of Liver Disease, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, China
| | - Le Huang
- College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Ke Wang
- College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Yaxi Yang
- College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Liu Chen
- College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Yun Peng
- Departments of Pediatrics Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yinming Liang
- Henan Key Laboratory of Immunology and Targeted Drug, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, Henan 453003, China
| | - Huabing Tan
- Department of Infectious Diseases, Lab of Liver Disease, Renmin Hospital, Hubei University of Medicine, Shiyan, Hubei 442000, China.
| | - Xiaoyan Wu
- Departments of Pediatrics Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China.
| | - Mingqian Feng
- College of Biomedicine and Health, Huazhong Agricultural University, Wuhan, Hubei 430070, China.
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Marjanska A, Styczynski J. Who is the patient at risk for EBV reactivation and disease: expert opinion focused on post-transplant lymphoproliferative disorders following hematopoietic stem cell transplantation. Expert Opin Biol Ther 2023:1-14. [PMID: 36971380 DOI: 10.1080/14712598.2023.2196366] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Post-transplant lymphoproliferative disorders (PTLD) represent a diverse group of diseases. They develop as a consequence of uncontrolled proliferation of lymphoid or plasmacytic cells resulting from T-cell immunosuppression after transplantation of either hematopoietic cells (HCT) or solid organs (SOT), caused mainly by latent Epstein-Barr virus (EBV). The risk for EBV recurrence is dependent on the level of incompetency of the immune system, presented as an impairment of T-cell immunity. AREAS COVERED This review summarizes the data on incidence and risk factors of EBV infection in patients after HCT. The median rate of EBV infection in HCT recipients was estimated at 30% after allogeneic and<1% after autologous transplant; 5% in non-transplant hematological malignancies; 30% in SOT recipients. The median rate of PTLD after HCT is estimated at 3%. The most frequently reported risk factors for EBV infection and disease include: donor EBV-seropositivity, use of T-cell depletion, especially with ATG; reduced-intensity conditioning; mismatched family or unrelated donor transplants; and acute or chronic graft-versus-host-disease. EXPERT OPINION The major risk factors for EBV infection and EBV-PTLD can be easily identified: EBV-seropositive donor, depletion of T-cells, and the use of immunosuppressive therapy. Strategies for avoiding risk factors include elimination EBV from the graft and improving T-cell function.
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Elitzur S, Vora A, Burkhardt B, Inaba H, Attarbaschi A, Baruchel A, Escherich G, Gibson B, Liu HC, Loh M, Moorman AV, Möricke A, Pieters R, Uyttebroeck A, Baird S, Bartram J, Barzilai-Birenboim S, Batra S, Ben-Harosh M, Bertrand Y, Buitenkamp T, Caldwell K, Drut R, Geerlinks AV, Gilad G, Grainger J, Haouy S, Heaney N, Huang M, Ingham D, Krenova Z, Kuhlen M, Lehrnbecher T, Manabe A, Niggli F, Paris C, Revel-Vilk S, Rohrlich P, Sinno MG, Szczepanski T, Tamesberger M, Warrier R, Wolfl M, Nirel R, Izraeli S, Borkhardt A, Schmiegelow K. EBV-driven lymphoid neoplasms associated with pediatric ALL maintenance therapy. Blood 2023; 141:743-755. [PMID: 36332176 DOI: 10.1182/blood.2022016975] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/19/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022] Open
Abstract
The development of a second malignancy after the diagnosis of childhood acute lymphoblastic leukemia (ALL) is a rare event. Certain second malignancies have been linked with specific elements of leukemia therapy, yet the etiology of most second neoplasms remains obscure and their optimal management strategies are unclear. This is a first comprehensive report of non-Hodgkin lymphomas (NHLs) following pediatric ALL therapy, excluding stem-cell transplantation. We analyzed data of patients who developed NHL following ALL diagnosis and were enrolled in 12 collaborative pediatric ALL trials between 1980-2018. Eighty-five patients developed NHL, with mature B-cell lymphoproliferations as the dominant subtype (56 of 85 cases). Forty-six of these 56 cases (82%) occurred during or within 6 months of maintenance therapy. The majority exhibited histopathological characteristics associated with immunodeficiency (65%), predominantly evidence of Epstein-Barr virus-driven lymphoproliferation. We investigated 66 cases of post-ALL immunodeficiency-associated lymphoid neoplasms, 52 from our study and 14 additional cases from a literature search. With a median follow-up of 4.9 years, the 5-year overall survival for the 66 patients with immunodeficiency-associated lymphoid neoplasms was 67.4% (95% confidence interval [CI], 56-81). Five-year cumulative risks of lymphoid neoplasm- and leukemia-related mortality were 20% (95% CI, 10.2-30) and 12.4% (95% CI, 2.7-22), respectively. Concurrent hemophagocytic lymphohistiocytosis was associated with increased mortality (hazard ratio, 7.32; 95% CI, 1.62-32.98; P = .01). A large proportion of post-ALL lymphoid neoplasms are associated with an immunodeficient state, likely precipitated by ALL maintenance therapy. Awareness of this underrecognized entity and pertinent diagnostic tests are crucial for early diagnosis and optimal therapy.
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Affiliation(s)
- Sarah Elitzur
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ajay Vora
- Department of Paediatric Haematology, Great Ormond Street Hospital, London, United Kingdom
| | - Birgit Burkhardt
- Pediatric Hematology and Oncology, University Hospital Münster, Münster, Germany
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria
| | - Andre Baruchel
- Department of Pediatric Hematology, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Gabriele Escherich
- Department of Pediatric Hematology and Oncoogy, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Brenda Gibson
- Department of Paediatric Haematology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Hsi-Che Liu
- Division of Pediatric Hematology/Oncology, Mackay Children's Hospital and Mackay Medical College, Taipei, Taiwan
| | - Mignon Loh
- Division of Pediatric Hematology, Oncology, Bone Marrow Transplant and Cellular Therapy, Seattle Children's Hospital and the Ben Towne Center for Childhood Cancer Research, University of Washington, Seattle, WA
| | - Anthony V Moorman
- Leukaemia Research Cytogenetics Group, Wolfson Childhood Cancer Centre, Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anja Möricke
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Anne Uyttebroeck
- Department of Paediatric Haematology and Oncology, University Hospital Leuven, Leuven, Leuven, Belgium
| | - Susan Baird
- Department of Haematology, Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - Jack Bartram
- Department of Paediatric Haematology, Great Ormond Street Hospital, London, United Kingdom
| | - Shlomit Barzilai-Birenboim
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Sandeep Batra
- Pediatric Hematology/Oncology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Miriam Ben-Harosh
- Department of Pediatric Hemato-Oncology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yves Bertrand
- Institut d'Hematologie et d'Oncologie Pediatrique, Hospices Civils de Lyon, Lyon, France
| | - Trudy Buitenkamp
- Amsterdam Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Kenneth Caldwell
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St Petersburg, FL
| | - Ricardo Drut
- Department of Pathology, School of Medicine, La Plata National University, La Plata, Argentina
| | | | - Gil Gilad
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - John Grainger
- Faculty of Medical & Human Sciences, University of Manchester and Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Stephanie Haouy
- Department of Pediatric Oncology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Nicholas Heaney
- Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Mary Huang
- Department of Pediatric Hematology Oncology, Massachusetts General Hospital for Children, Harvard Medical School, Boston, MA
| | - Danielle Ingham
- Paediatric Oncology, Leeds Children's Hospital, Leeds, United Kingdom
| | - Zdenka Krenova
- Department of Pediatric Oncology and Department of Pediatrics, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michaela Kuhlen
- Pediatrics and Adolescent Medicine, University of Augsburg, Augsburg, Germany
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Hospital for Children and Adolescents, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Atsushi Manabe
- Department of Pediatrics, Hokkaido University, Graduate School of Medicine, Sapporo, Japan
| | - Felix Niggli
- Department of Pediatric Oncology, University Children's Hospital, Zurich, Switzerland
| | - Claudia Paris
- Department of Pediatric Oncology and Hematology, Hospital Luis Calvo Mackenna, Santiago, Chile
| | - Shoshana Revel-Vilk
- Shaare Zedek Medical Centre and The Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Mohamad G Sinno
- Phoenix Children's Hospital, Center for Cancer and Blood Disorders, Phoenix, AZ
| | - Tomasz Szczepanski
- Department of Pediatric Hematology and Oncology, Zabrze and Medical University of Silesia, Katowice, Poland
| | - Melanie Tamesberger
- Department of Pediatrics and Adolescent Medicine, Kepler University Clinic, Linz, Austria
| | | | - Matthias Wolfl
- Pediatric Oncology, Hematology and Stem Cell Transplantation Program, University Children's Hospital Würzburg, Würzburg, Germany
| | - Ronit Nirel
- Department of Statistics and Data Science, Hebrew University, Jerusalem, Israel
| | - Shai Izraeli
- Department of Pediatric Hematology and Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Arndt Borkhardt
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Medical Faculty, Heinrich-Heine University, Duesseldorf, Germany
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, The University Hospital, Rigshospitalet, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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[Chinese consensus on the diagnosis and management of Epstein-Barr virus-related post-transplant lymphoproliferative disorders after hematopoietic stem cell transplantation (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:716-725. [PMID: 36709164 PMCID: PMC9613495 DOI: 10.3760/cma.j.issn.0253-2727.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Quintero Bernabeu J, Juamperez J, Mercadal-Hally M, Larrarte King M, Gallego Melcon S, Gros Subias L, Sábado Álvarez C, Soler-Palacin P, Melendo Pérez S, Esperalba J, Navarro Jiménez A, Garrido Pontnou M, Camacho Soriano J, Hidalgo Llompart E, Bilbao Aguirre I, Charco Torra R. Epstein-Barr virus-associated risk factors for post-transplant lymphoproliferative disease in pediatric liver transplant recipients. Pediatr Transplant 2022; 26:e14292. [PMID: 35466492 DOI: 10.1111/petr.14292] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 02/11/2022] [Accepted: 03/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Post-transplant lymphoproliferative disorder (PTLD) are the most common de novo malignancies after liver transplantation (LT) in children. The aim of our study was to assess the role of pre-LT EBV status and post-LT EBV viral load as risk factors for developing PTLD in a cohort of pediatric LT recipients. METHODS Data of all children who underwent LT between January 2002 and December 2019 were collected. Two cohorts were built EBV pre-LT primary infected cohort and EBV post-LT primary infected cohort. Moreover, using the maximal EBV viral load, a ROC curve was constructed to find a cutoff point for the diagnosis of PTLD. RESULTS Among the 251 patients included in the study, fifteen PTLD episodes in 14 LT recipients were detected (2 plasmacytic hyperplasia, 10 polymorphic PTLD, 2 monomorphic PTLD, and 1 Classical-Hodgkin's lymphoma). Patients of the EBV post-LT primary infected cohort were 17.1 times more likely to develop a PTLD than patients of the EBV pre-LT primary infected cohort (2.2-133.5). The EBV viral load value to predict PTLD was set at 211 000 UI/mL (93.3% sensitivity and 77.1% specificity; AUC 93.8%; IC 0.89-0.98). In EBV post-LT primary infected cohort, patients with a viral load above 211 000 were 30 times more likely to develop PTLD than patients with a viral load below this value (OR 29.8; 3.7-241.1; p < 0.001). CONCLUSIONS The combination of pretransplant EBV serological status with EBV post-transplant viral load could be a powerful tool to stratify the risk of PTLD in pediatric LT patients.
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Affiliation(s)
- Jesus Quintero Bernabeu
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Javier Juamperez
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Maria Mercadal-Hally
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Mauricio Larrarte King
- Pediatric Hepatology and Liver Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Soledad Gallego Melcon
- Pediatric Oncology and Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Luis Gros Subias
- Pediatric Oncology and Hematology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Susana Melendo Pérez
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Juliana Esperalba
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | | | | | - Ernest Hidalgo Llompart
- HPB Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Itxarone Bilbao Aguirre
- HPB Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ramón Charco Torra
- HPB Surgery and Transplantation Department, Vall d'Hebron University Hospital, Barcelona, Spain
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Sobkowiak-Sobierajska A, Lindemans C, Sykora T, Wachowiak J, Dalle JH, Bonig H, Gennery A, Lawitschka A. Management of Chronic Graft-vs.-Host Disease in Children and Adolescents With ALL: Present Status and Model for a Personalised Management Plan. Front Pediatr 2022; 10:808103. [PMID: 35252060 PMCID: PMC8894895 DOI: 10.3389/fped.2022.808103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/24/2022] [Indexed: 12/18/2022] Open
Abstract
Herein we review current practice regarding the management of chronic graft-vs.-host disease (cGvHD) in paediatric patients after allogeneic haematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukaemia (ALL). Topics covered include: (i) the epidemiology of cGvHD; (ii) an overview of advances in our understanding cGvHD pathogenesis; (iii) current knowledge regarding risk factors for cGvHD and prevention strategies complemented by biomarkers; (iii) the paediatric aspects of the 2014 National Institutes for Health-defined diagnosis and grading of cGvHD; and (iv) current options for cGvHD treatment. We cover topical therapy and newly approved tyrosine kinase inhibitors, emphasising the use of immunomodulatory approaches in the context of the delicate counterbalance between immunosuppression and immune reconstitution as well as risks of relapse and infectious complications. We examine real-world approaches of response assessment and tapering schedules of treatment. Furthermore, we report on the optimal timepoints for therapeutic interventions and changes in relation to immune reconstitution and risk of relapse/infection. Additionally, we review the different options for anti-infectious prophylaxis. Finally, we put forth a theory of a holistic view of paediatric cGvHD and its associated manifestations and propose a checklist for individualised risk evaluation with aggregated considerations including site-specific cGvHD evaluation with attention to each individual's GvHD history, previous medical history, comorbidities, and personal tolerance and psychosocial circumstances. To complement this checklist, we present a treatment algorithm using representative patients to inform the personalised management plans for patients with cGvHD after HSCT for ALL who are at high risk of relapse.
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Affiliation(s)
| | - Caroline Lindemans
- Department of Pediatrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Pediatric Blood and Bone Marrow Transplantation, Princess Máxima Center, Utrecht, Netherlands
| | - Tomas Sykora
- Department of Pediatric Hematology and Oncology - Haematopoietic Stem Cell Transplantation Unit, National Institute of Children's Diseases and Medical Faculty, Comenius University, Bratislava, Slovakia
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jean-Hugues Dalle
- Hematology and Immunology Department, Robert-Debré Hospital, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Halvard Bonig
- Goethe University Medical Center, Institute of Transfusion Medicine and Immunohematology, and German Red Cross Blood Center Frankfurt, Frankfurt, Germany
| | - Andrew Gennery
- Medical School, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anita Lawitschka
- Stem Cell Transplantation Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute, Vienna, Austria
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Hosoi H, Matsuyama Y, Murata S, Mushino T, Sonoki T. Prolonged Epstein-Barr virus reactivation coincident with chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Leuk Lymphoma 2021; 63:1009-1012. [PMID: 34784844 DOI: 10.1080/10428194.2021.2005047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Hiroki Hosoi
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Yoriko Matsuyama
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Shogo Murata
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Toshiki Mushino
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Takashi Sonoki
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
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9
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Enok Bonong PR, Buteau C, Duval M, Lacroix J, Laporte L, Tucci M, Robitaille N, Spinella PC, Cuvelier GDE, Lewis V, Vercauteren S, Alfieri C, Trottier H. Risk factors for post-transplant Epstein-Barr virus events in pediatric recipients of hematopoietic stem cell transplants. Pediatr Transplant 2021; 25:e14052. [PMID: 34076939 DOI: 10.1111/petr.14052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Epstein-Barr virus (EBV) can cause severe disease following hematopoietic stem cell transplant (HSCT), including post-transplant lymphoproliferative disorder (PTLD). The objective was to analyze risk factors associated with post-transplant EBV outcomes among pediatric allogeneic HSCT recipients. METHODS We used data from 156 pediatric allogeneic HSCT recipients enrolled in the Canadian multicenter TREASuRE study. Cox and Prentice-Williams-Petersen models were used to analyze risk factors for post-transplant EBV events including occurrence and recurrence of EBV DNAemia, increase in EBV viral load (EBV-VL), and preemptive use of rituximab, an effective therapy against PTLD. RESULTS Females were at higher risk for increasing EBV-VL (adjusted hazard ratio (HR) = 2.83 [95% confidence intervals (CI): 1.33-6.03]) and rituximab use (HR = 3.08 [1.14-8.30]), but had the same EBV DNAemia occurrence (HR = 1.21 [0.74-1.99]) and recurrence risks (HR=1.05 [0.70-1.58]) compared to males. EBV DNAemia was associated with recipient pre-transplant EBV seropositivity (HR = 2.47 [1.17-5.21]) and with graft from an EBV-positive donor (HR = 3.53 [1.95-6.38]). Anti-thymocyte globulin (ATG) was strongly associated with all EBV outcomes, including the use of rituximab (HR = 5.33 [1.47-19.40]). Mycophenolate mofetil (MMF) significantly decreased the risk of all EBV events including the rituximab use (HR = 0.13 [0.03-0.63]). CONCLUSION This study in pediatric allogeneic HSCT patients reveals a reduced risk of all EBV outcomes with the use of MMF. Risk factors for EBV events such as EBV-VL occurrence and recurrence include EBV positivity in the donor and recipient, and use of ATG, whereas risk factors for the most severe forms of EBV outcome (EBV-VL and the use of rituximab) include female sex and ATG use.
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Affiliation(s)
- Pascal R Enok Bonong
- Department of Social and Preventive Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Chantal Buteau
- Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Michel Duval
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jacques Lacroix
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Louise Laporte
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, QC, Canada
| | - Marisa Tucci
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Nancy Robitaille
- Division of Hematology-Oncology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Héma-Québec, Montreal, QC, Canada
| | - Philip C Spinella
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - Geoffrey D E Cuvelier
- Pediatric Blood and Marrow Transplant, Department of Pediatric Hematology-Oncology-BMT, Department of Pediatrics and Child Health, CancerCare Manitoba, University of Manitoba, Winnipeg, MB, Canada
| | - Victor Lewis
- Department of Pediatrics and Department of Oncology, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Suzanne Vercauteren
- Department of Pathology and Laboratory Medicine, BC Children's Hospital, University of British Colombia, Vancouver, BC, Canada
| | - Caroline Alfieri
- Department of Microbiology, Infectiology and Immunology, Centre de recherche du CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Helen Trottier
- Department of Social and Preventive Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
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Marzolini MAV, Wilson AJ, Sanchez E, Carpenter B, Chakraverty R, Hough R, Kottaridis P, Morris EC, Thomson KJ, Peggs KS. Natural History of Epstein-Barr Virus Replication and Viral Load Dynamics after Alemtuzumab-Based Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2021; 27:682.e1-682.e12. [PMID: 33962069 DOI: 10.1016/j.jtct.2021.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/02/2021] [Accepted: 04/25/2021] [Indexed: 01/27/2023]
Abstract
Epstein-Barr virus (EBV) load monitoring after allogeneic hematopoietic stem cell transplantation (HSCT) enables earlier detection of EBV replication and often serves as a trigger for preemptive therapies aimed at reducing EBV-related diseases. Our institutional strategy is to treat patients with clinical signs of EBV-related disease accompanied by a rising viral load, rather than to intervene based solely on viral load. This affords an opportunity to study the natural history of EBV replication and to assess whether our strategy reduces overtreatment without compromising outcomes. The objectives of the present study were to assess the natural history of untreated EBV replication in patients who underwent an alemtuzumab-based allogeneic HSCT and to examine whether our clinical strategy reduced overtreatment without compromising patient outcomes. In this retrospective single-center observational study of 515 consecutive patients (age ≥18 years) undergoing T cell-depleted allogeneic HSCT incorporating alemtuzumab, patients underwent surveillance monitoring for EBV by quantitative PCR in the peripheral blood at least weekly up to 100 days post-transplantation and longer if they remained on immunosuppressive therapy. The cumulative incidence of EBV detection and EBV-related disease were assessed. Among the 515 patients, 192 had EBV DNA detectable on ≥1 occasion, with a cumulative incidence of 35.8% (31.8% to 40.4%), although this remained below the limit of quantification in 93 patients. The median time to first detection was 89.5 days (range, 0 to 2254 days). The incidence was higher in recipients of sibling donor transplants (45.4% versus 30%; P = .00021) compared with recipients of unrelated donor transplants. Twenty patients developed EBV-related disease (cumulative incidence, 3.9%). Two patients had immunosuppression reduction alone, 18 received rituximab, and 5 required additional therapies. Five patients died from post-transplantation lymphoproliferative disorder, all of whom had received rituximab. The positive predictive value of EBV load for disease was higher in the unrelated donor cohort but remained <75% regardless of EBV threshold (57.1% to 72.7%). The cumulative incidence of EBV-related disease in our study (3.9%) is comparable to that reported in other studies incorporating alemtuzumab, and our clinical strategy reduced overtreatment in this patient population. PCR-based surveillance strategies have limitations, as reflected in the relatively low sensitivity of the assay coupled with the low positive predictive value, which may influence the potential choice of a threshold for preemptive intervention. We conclude that it remains unclear whether treatment based on a rising EBV viral load alone provides superior overall results to treatment based on the development of clinical signs of EBV-related disease in the context of a rising viral load.
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Affiliation(s)
- Maria A V Marzolini
- Department of Haematology, UCL Cancer Institute, University College London, London, Uinted Kingdom; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.
| | - Andrew J Wilson
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Emilie Sanchez
- Department of Virology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Ben Carpenter
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Ronjon Chakraverty
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rachael Hough
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Panos Kottaridis
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Emma C Morris
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Kirsty J Thomson
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Karl S Peggs
- Department of Haematology, UCL Cancer Institute, University College London, London, Uinted Kingdom; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
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11
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Factors Associated with Post-Transplant Active Epstein-Barr Virus Infection and Lymphoproliferative Disease in Hematopoietic Stem Cell Transplant Recipients: A Systematic Review and Meta-Analysis. Vaccines (Basel) 2021; 9:vaccines9030288. [PMID: 33808928 PMCID: PMC8003684 DOI: 10.3390/vaccines9030288] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 12/29/2022] Open
Abstract
This systematic review was undertaken to identify risk factors associated with post-transplant Epstein–Barr virus (EBV) active infection and post-transplant lymphoproliferative disease (PTLD) in pediatric and adult recipients of hematopoietic stem cell transplants (HSCT). A literature search was conducted in PubMed and EMBASE to identify studies published until 30 June 2020. Descriptive information was extracted for each individual study, and data were compiled for individual risk factors, including, when possible, relative risks with 95% confidence intervals and/or p-values. Meta-analyses were planned when possible. The methodological quality and potential for bias of included studies were also evaluated. Of the 3362 titles retrieved, 77 were included (62 for EBV infection and 22 for PTLD). The overall quality of the studies was strong. Several risk factors were explored in these studies, but few statistically significant associations were identified. The use of anti-thymocyte globulin (ATG) was identified as the most important risk factor positively associated with post-transplant active EBV infection and with PTLD. The pooled relative risks obtained using the random-effect model were 5.26 (95% CI: 2.92–9.45) and 4.17 (95% CI: 2.61–6.68) for the association between ATG and post-transplant EBV infection and PTLD, respectively. Other risk factors for EBV and PTLD were found in the included studies, such as graft-versus-host disease, type of conditioning regimen or type of donor, but results are conflicting. In conclusion, the results of this systematic review indicate that ATG increases the risk of EBV infection and PTLD, but the link with all other factors is either nonexistent or much less convincing.
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12
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Post-transplantation lymphoproliferative disorder after haematopoietic stem cell transplantation. Ann Hematol 2021; 100:865-878. [PMID: 33547921 DOI: 10.1007/s00277-021-04433-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/18/2021] [Indexed: 12/19/2022]
Abstract
Post-transplantation lymphoproliferative disorder (PTLD) is a severe complication of haematopoietic stem cell transplantation (HSCT), occurring in a setting of immune suppression and dysregulation. The disease is in most cases driven by the reactivation of the Epstein-Barr virus (EBV), which induces B cell proliferation through different pathomechanisms. Beyond EBV, many factors, variably dependent on HSCT-related immunosuppression, contribute to the disease development. PTLDs share several features with primary lymphomas, though clinical manifestations may be different, frequently depending on extranodal involvement. According to the WHO classification, histologic examination is required for diagnosis, allowing also to distinguish among PTLD subtypes. However, in cases of severe and abrupt presentation, a diagnosis based on a combination of imaging studies and EBV-load determination is accepted. Therapies include prophylactic and pre-emptive interventions, aimed at eradicating EBV proliferation before symptoms onset, and targeted treatments. Among them, rituximab has emerged as first-line option, possibly combined with a reduction of immunosuppression, while EBV-specific cytotoxic T lymphocytes are effective and safe alternatives. Though prognosis remains poor, survival has markedly improved following the adoption of the aforementioned treatments. The validation of innovative, combined approaches is the future challenge.
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Bacigalupo A, Metafuni E, Amato V, Marquez Algaba E, Pagano L. Reducing infectious complications after allogeneic stem cell transplant. Expert Rev Hematol 2020; 13:1235-1251. [PMID: 32996342 DOI: 10.1080/17474086.2020.1831382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Infections remain a significant problem, in patients undergoing an allogeneic hematopoietic stem-cell transplant (HSCT) and efforts have been made over the years, to reduce the incidence, morbidity and mortality of infectious complications. AREAS COVERED This manuscript is focused on the epidemiology, risk factors and prevention of infections after allogeneic HSCT. A systematic literature review was performed using the PubMed database, between November 2019 and January 2020, with the following MeSH terms: stem-cell transplantation, infection, fungal, bacterial, viral, prophylaxis, vaccines, prevention. The authors reviewed all the publications, and following a common revision, a summary report was made and results were divided in three sections: bacterial, fungal and viral infections. EXPERT OPINION Different infections occur in the early, intermediate and late post-transplant period, due to distinct risk factors. Improved diagnostic techniques, pre-emtive therapy and better prophylaxis of immunologic complications, have reduced the morbidity and mortality of infections. The role of the gut microbiota is under careful scrutiny and may further help us to identify high-risk patients.
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Affiliation(s)
- Andrea Bacigalupo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Elisabetta Metafuni
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Viviana Amato
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy
| | - Ester Marquez Algaba
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona , Barcelona, Spain
| | - Livio Pagano
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli- IRCCS , Rome, Italy.,Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica Del Sacro Cuore , Rome, Italy
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14
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Enok Bonong PR, Buteau C, Delage G, Tanner JE, Lacroix J, Duval M, Laporte L, Tucci M, Robitaille N, Spinella PC, Cuvelier G, Vercauteren S, Lewis V, Fearon M, Drews SJ, Alfieri C, Trottier H. Transfusion-related Epstein-Barr virus (EBV) infection: A multicenter prospective cohort study among pediatric recipients of hematopoietic stem cell transplants (TREASuRE study). Transfusion 2020; 61:144-158. [PMID: 33089891 DOI: 10.1111/trf.16149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/31/2020] [Accepted: 09/11/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Epstein-Barr virus (EBV) is carried in the blood of most adults, and transfusion-related infections have been reported. EBV is particularly deleterious in immunosuppressed transplant patients. The aim was to determine if EBV transmission occurred through leukodepleted blood product transfusion in pediatric recipients of hematopoietic stem cell transplants (HSCT). STUDY DESIGN AND METHODS This prospective Canadian multi-center cohort study includes 156 allogeneic HSCT pediatric recipients. The association between EBV and transfusion was analyzed using Cox regressions. EBV infection, defined by a PCR+ test in the blood of seronegative recipients of an EBV-negative graft, was monitored in order to correlate the recipient EBV strain with that of the blood donors. EBV genotypes were determined by PCR amplification followed by DNA sequencing at two loci (EBNA3b and LMP1). RESULTS No statistically significant associations were found between transfusions and EBV. One case of post-transplant EBV infection was identified among the 21 EBV-seronegative recipients receiving an EBV-negative graft. A total of 22 blood donors were retraced to determine whether the recipient's EBV strain matched that of a donor. One donor strain showed 100% sequence homology at the EBNA3b locus, but differed by one or two point mutations and by a 132-bp deletion at the LMP1 locus. The blood donor in question was alone among the 22 donors to show amplifiable virus in plasma. Blood from this donor readily produced an immortalized lymphoblastoid cell line in culture. CONCLUSION While considered a rare event, EBV transmission through transfusion may occur in the context of severe immunosuppression.
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Affiliation(s)
- Pascal R Enok Bonong
- Department of Social and Preventive Medicine, Université de Montréal, Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Chantal Buteau
- Division of Infectious Diseases, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Gilles Delage
- Medical Affairs, Microbiology, Héma-Québec, Ville St-Laurent, Quebec, Canada
| | - Jerome E Tanner
- Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Jacques Lacroix
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Michel Duval
- Division of Hematology-Oncology, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Louise Laporte
- Sainte-Justine University Hospital, Montreal, Quebec, Canada
| | - Marisa Tucci
- Division of Pediatric Intensive Care Medicine, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal, Montreal, Quebec, Canada
| | - Nancy Robitaille
- Division of Hematology-Oncology, Department of Pediatrics, Sainte-Justine University Hospital, Université de Montréal and Medical Affairs, Transfusion Medicine, Héma-Québec, Ville Saint-Laurent, Quebec, Canada
| | - Philip C Spinella
- St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Geoffrey Cuvelier
- Department of Pediatrics and Child Health, CancerCare Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Suzanne Vercauteren
- Department of Pathology and Laboratory Medicine, BC Children's Hospital, University of British Colombia, Vancouver, British Columbia, Canada
| | - Victor Lewis
- Department of Pediatrics and Department of Oncology, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Margaret Fearon
- Medical Microbiology, Canadian Blood Services, Toronto, Ontario, Canada
| | - Steven J Drews
- Medical Affairs and Innovation, Microbiology, Canadian Blood Services and University of Alberta, Laboratory Medicine and Pathology, Edmonton, Alberta, Canada
| | - Carolina Alfieri
- Department of Microbiology, Infectiology and Immunology, Université de Montréal, Sainte-Justine University Hospital Research Centre, Université de Montréal, Montreal, Quebec, Canada
| | - Helen Trottier
- Department of Social and Preventive Medicine, Université de Montréal, Sainte-Justine University Hospital, Montreal, Quebec, Canada
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15
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Lam JKP, Azzi T, Hui KF, Wong AMG, McHugh D, Caduff N, Chan KH, Münz C, Chiang AKS. Co-infection of Cytomegalovirus and Epstein-Barr Virus Diminishes the Frequency of CD56 dimNKG2A +KIR - NK Cells and Contributes to Suboptimal Control of EBV in Immunosuppressed Children With Post-transplant Lymphoproliferative Disorder. Front Immunol 2020; 11:1231. [PMID: 32625211 PMCID: PMC7311655 DOI: 10.3389/fimmu.2020.01231] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/15/2020] [Indexed: 01/19/2023] Open
Abstract
Post-transplant lymphoproliferative disorder (PTLD) is a rare but potentially life-threatening complication, frequently associated with Epstein-Barr virus (EBV), which develops after solid organ or stem cell transplantation. Immunosuppression received by transplant recipients has a significant impact on the development of PTLD by suppressing the function of T cells. The preferential proliferation of NKG2A-positive natural killer (NK) cells during primary symptomatic EBV infection known as infectious mononucleosis (IM) and their reactivity toward EBV-infected B cells point to a role of NK cell in the immune control of EBV. However, NK cell-mediated immune response to EBV in immunosuppressed transplant recipients who develop PTLD remains unclear. In this study, we longitudinally analyzed the phenotype and function of different NK cell subsets in a cohort of pediatric liver transplant patients who develop PTLD and compared them to those of children with IM. We found persistently elevated plasma EBV DNA levels in the PTLD patients indicating suboptimal anti-viral immune control. PTLD patients had markedly decreased frequency of CD56dimNKG2A+Killer Immunoglobulin-like receptor (KIR)− NK cells from the time of diagnosis through remission compared to those of IM patients. Whilst the proliferation of CD56dimNKG2A+KIR− NK cells was diminished in PTLD patients, this NK cell subset maintained its ability to potently degranulate against EBV-infected B cells. Compared to cytomegalovirus (CMV)-seropositive and -negative IM patients, PTLD patients co-infected with CMV and EBV had significantly higher levels of a CMV-associated CD56dimNKG2ChiCD57+NKG2A−KIR+ NK cell subset accumulating at the expense of NKG2A+KIR− NK cells. Taken together, our data indicate that co-infection of CMV and EBV diminishes the frequency of CD56dimNKG2A+KIR− NK cells and contributes to suboptimal control of EBV in immunosuppressed children with PTLD.
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Affiliation(s)
- Janice K P Lam
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tarik Azzi
- Experimental Infectious Diseases and Cancer Research, University Children's Hospital of Zurich, Zurich, Switzerland
| | - K F Hui
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Aikha M G Wong
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Donal McHugh
- Department of Viral Immunobiology, Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Nicole Caduff
- Department of Viral Immunobiology, Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - K H Chan
- Department of Microbiology, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Christian Münz
- Department of Viral Immunobiology, Institute of Experimental Immunology, University of Zurich, Zurich, Switzerland
| | - Alan K S Chiang
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, The University of Hong Kong, Pok Fu Lam, Hong Kong
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16
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Luo XY, Mo XD, Xu LP, Zhang XH, Wang Y, Liu KY, Chang YJ, Zhao XY, Huang XJ. A retrospective analysis on anti-CD20 antibody-treated Epstein-Barr virus-related posttransplantation lymphoproliferative disorder following ATG-based haploidentical T-replete hematopoietic stem cell transplantation. Ann Hematol 2020; 99:2649-2657. [PMID: 32206854 DOI: 10.1007/s00277-020-04003-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/12/2020] [Indexed: 11/26/2022]
Abstract
Posttransplantation lymphoproliferation disorder (PTLD) is a life-threatening complication after hematopoietic stem cell transplantation (HSCT). Anti-CD20 antibody is the most widely used antibody to eliminate infected B cells. Few studies have focused on prognostic factors predicting the outcome of EBV (Epstein-Barr virus)-PTLD. We conducted a retrospective analysis of 2571 haplo-HSCTs performed between 2010 and 2017 at the Peking University Institute of Hematology; seventy patients who had been treated with rituximab for PTLD were enrolled. The overall EBV-related PTLD frequency was 3.1%. With a median follow-up time of 365 days (range, 54-2659), the overall survival rate was 51.43% (36/70). The cumulative incidence of EBV-PTLD complete remission with anti-CD20 antibody monotherapy was 68.57% (48/70). EBV-PTLD-related mortality was 11.43% (8/70), while the transplantation-related mortality was 38.57% (27/70). Multivariate analysis showed that a decrease in EBV viral load 1 week after therapy was associated with high response rate of EBV-PTLD (p = 0.007, 0.106 (0.021-0.549)), low PTLD-related mortality (p = 0.010, HR 0.058 (0.007-0.503)), and transplantation-related mortality (p = 0.051, HR 0.441 (0.194-1.003)). For EBV-PTLD patients after haplo-HSCT who received rituximab as first-line therapy, non-decreased EBV viral load 1 week after anti-CD20 therapy could be high risk factor for poor outcomes.
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Affiliation(s)
- Xue-Yi Luo
- 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, 100044, 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, 100044, China
| | - Lan-Ping Xu
- 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, 100044, China
| | - Xiao-Hui 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, 100044, China
| | - Yu Wang
- 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, 100044, China
| | - Kai-Yan Liu
- 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, 100044, China
| | - Ying-Jun Chang
- 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, 100044, China
| | - Xiang-Yu Zhao
- 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, 100044, China.
| | - Xiao-Jun Huang
- 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, 100044, China.
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17
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Santos CAQ, Rhee Y, Czapka MT, Kazi AS, Proia LA. Make Sure You Have a Safety Net: Updates in the Prevention and Management of Infectious Complications in Stem Cell Transplant Recipients. J Clin Med 2020; 9:jcm9030865. [PMID: 32245201 PMCID: PMC7141503 DOI: 10.3390/jcm9030865] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
Hematopoietic stem cell transplant recipients are at increased risk of infection and immune dysregulation due to reception of cytotoxic chemotherapy; development of graft versus host disease, which necessitates treatment with immunosuppressive medications; and placement of invasive catheters. The prevention and management of infections in these vulnerable hosts is of utmost importance and a key “safety net” in stem cell transplantation. In this review, we provide updates on the prevention and management of CMV infection; invasive fungal infections; bacterial infections; Clostridium difficile infection; and EBV, HHV-6, adenovirus and BK infections. We discuss novel drugs, such as letermovir, isavuconazole, meropenem-vaborbactam and bezlotoxumab; weigh the pros and cons of using fluoroquinolone prophylaxis during neutropenia after stem cell transplantation; and provide updates on important viral infections after hematopoietic stem cell transplant (HSCT). Optimizing the prevention and management of infectious diseases by using the best available evidence will contribute to better outcomes for stem cell transplant recipients, and provide the best possible “safety net” for these immunocompromised hosts.
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18
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Hyun H, Park E, Cho M, Min SI, Ha J, Kang HJ, Shin HY, Ha IS, Cheong HI, Ahn YH, Kang HG. Post-Transplant Lymphoproliferative Diseases in Pediatric Kidney Allograft Recipients with Epstein-Barr Virus Viremia. J Korean Med Sci 2019; 34:e203. [PMID: 31373185 PMCID: PMC6676002 DOI: 10.3346/jkms.2019.34.e203] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 07/07/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Post-transplant lymphoproliferative disease (PTLD) is one of the major complications of organ transplantation, especially in children with Epstein-Barr virus (EBV) viremia (EV). We performed a retrospective study to evaluate risk factors for PTLD in children with EV. METHODS Among 199 pediatric kidney transplantation (KT) recipients at our center from January 2001 to October 2015, records of those with EBV viral loads of > 1,000 copies/mL and/or PTLD were reviewed. RESULTS Diagnosis of PTLD was made in seven patients (PTLD group), and 39 patients had EV only (EV only group). The median time from KT to EV and PTLD diagnosis was 6.7 (range 0.4-47.8) months and 8.2 (range, 2.8-98.9) months, respectively. There were no significant differences between the groups in terms of sex, age at transplantation, donor type, EBV viral load, or EV-free duration after KT. Higher tacrolimus level before EV (hazard ratio, 44.5; P = 0.003) was an independent risk factor for PTLD in multivariate Cox regression analysis. Six patients with a high EBV load (median 171,639 copies/mL) were treated with preemptive rituximab (RTX) therapy, resulting in transient reduction of EBV load. None of these patients developed PTLD (median follow-up 51.5 months); however, two had neutropenia and two developed infection requiring hospital admission. CONCLUSION In pediatric KT recipients, higher tacrolimus levels were associated with a higher incidence of PTLD. Conversely, those who received preemptive RTX for EV did not develop PTLD.
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Affiliation(s)
- Hyesun Hyun
- Department of Pediatrics, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eujin Park
- Department of Pediatrics, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Myunghyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Il Min
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Seoul, Korea
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Cancer Research Institute, Seoul, Korea
| | - Il Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea.
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19
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Wang H, Zhang TT, Qi JQ, Chu TT, Miao M, Qiu HY, Fu CC, Tang XW, Ruan CG, Wu DP, Han Y. Incidence, risk factors, and clinical significance of Epstein-Barr virus reactivation in myelodysplastic syndrome after allogeneic haematopoietic stem cell transplantation. Ann Hematol 2019; 98:987-996. [PMID: 30715567 DOI: 10.1007/s00277-019-03603-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 01/04/2019] [Indexed: 11/30/2022]
Abstract
Epstein-Barr virus (EBV) reactivation is a life-threatening complication after allogeneic haematopoietic stem cell transplantation (allo-HSCT). In this study, we investigated the characteristics of EBV reactivation in 186 consecutive myelodysplastic (MDS) patients who underwent allo-HSCT in our centre. In 35 patients (18.8%) who experienced EBV reactivation after allo-HSCT, the median onset was 53 days (range 4-381 days). The cumulative incidence of EBV reactivation at the first, sixth, and twelfth month after allo-HSCT was 10.7%, 15.1%, and 17.9%, respectively. Twenty-five patients (71.4%) received pre-emptive rituximab therapy, and no patients developed post-transplant lymphoproliferative disorders. Stem cell source was proven to be a risk factor correlated with EBV reactivation. The cumulative incidence of relapse in the EBV-positive group was 11.4%, 25.2%, and 31.0% at the first, second, and third year after transplantation, respectively, being significantly higher than the corresponding 6.8%, 10.2%, and 10.2%, in the EBV-negative group (P = 0.014). Prognostic analysis showed that EBV reactivation was an independent risk factor for relapse-free survival (RFS). Patients in the EBV-positive group showed obviously shorter RFS than those in the EBV-negative group, with 3-year RFS of 62% and 85%, respectively (P = 0.017).
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Affiliation(s)
- Hong Wang
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Tong-Tong Zhang
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Jia-Qian Qi
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China
| | - Tian-Tian Chu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Miao Miao
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Hui-Ying Qiu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Cheng-Cheng Fu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Xiao-Wen Tang
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - Chang-Geng Ruan
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China.,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China
| | - De-Pei Wu
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China. .,Institute of Blood and Marrow Transplantation, Suzhou, China. .,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China. .,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China.
| | - Yue Han
- Jiangsu Institute of Haematology, The First Affiliated Hospital of Soochow University, Suzhou, China. .,Institute of Blood and Marrow Transplantation, Suzhou, China. .,Key Laboratory of Thrombosis and Haemostasis of Ministry of Health, Suzhou, China. .,Collaborative Innovation Centre of Haematology, Soochow University, Suzhou, China.
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20
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Danylesko I, Shimoni A. Second Malignancies after Hematopoietic Stem Cell Transplantation. Curr Treat Options Oncol 2018; 19:9. [PMID: 29423555 DOI: 10.1007/s11864-018-0528-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OPINION STATEMENT Second malignancies are a rare but well-defined late complication after autologous and allogeneic hematopoietic stem-cell transplantation (SCT). Solid malignancies occur in up to 15% of patients 15 years after SCT with myeloablative conditioning, with no plateau in the incidence rates. They are responsible for 5-10% of late deaths after SCT. The incidence is increased with advanced age at SCT. The major risk factors are the use of total body irradiation, which is associated with adenocarcinomas and with chronic graft-versus-host disease which is associated with squamous cell cancers. There is less data on the incidence of second malignancies after reduced-intensity conditioning, but it may not be lower. The types of solid tumors reported in excess include melanoma and other skin cancers; cancers of the oral cavity and head and neck, brain, liver, uterine cervix, thyroid, breast, lung; and possibly gastrointestinal cancers. Therapy-related myeloid neoplasms (t-MN) are more common after autologous SCT and may be related mostly to pre-transplant therapies. Post-transplant lymphoproliferative disease is donor-cell-derived lymphoma that is more common after allogeneic SCT with T-cell depletion or intensive immune-suppression state. Second malignancies are most often treated similarly to the standard therapy for similar malignancies. Lifelong cancer screening and prevention interventions are required for all transplantation survivors.
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Affiliation(s)
- Ivetta Danylesko
- The Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sacker school of medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avichai Shimoni
- The Division of Hematology and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel Hashomer, Israel. .,Sacker school of medicine, Tel-Aviv University, Tel-Aviv, Israel.
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21
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Abstract
Infection is a major complication of patients with hematological malignancies. Prophylaxis is a key element in the management of these patients, and is composed by two main components: infection control measures and antimicrobial chemoprophylaxis. Infection control measures are safe, but not always effective. Antimicrobial prophylaxis is usually effective but may increase resistance rates, toxicity, and cost. Therefore, a careful evaluation of the actual risk for infection, the pathogens that predominate in a particular setting, and the periods at risk are important in order to define the most appropriate strategy. In this chapter we review the most important parameters to assess the risk on an individual basis, and the evidences and recommendations supporting infection control measures and antimicrobial prophylaxis against bacteria, fungi, viruses, and parasites.
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22
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Styczynski J, van der Velden W, Fox CP, Engelhard D, de la Camara R, Cordonnier C, Ljungman P. Management of Epstein-Barr Virus infections and post-transplant lymphoproliferative disorders in patients after allogeneic hematopoietic stem cell transplantation: Sixth European Conference on Infections in Leukemia (ECIL-6) guidelines. Haematologica 2017; 101:803-11. [PMID: 27365460 DOI: 10.3324/haematol.2016.144428] [Citation(s) in RCA: 235] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/21/2016] [Indexed: 12/11/2022] Open
Abstract
Epstein-Barr virus-related post-transplant lymphoproliferative disorders are recognized as a significant cause of morbidity and mortality in patients undergoing hematopoietic stem cell transplantation. To better define current understanding of post-transplant lymphoproliferative disorders in stem cell transplant patients, and to improve its diagnosis and management, a working group of the Sixth European Conference on Infections in Leukemia 2015 reviewed the literature, graded the available quality of evidence, and developed evidence-based recommendations for diagnosis, prevention, prophylaxis and therapy of post-transplant lymphoproliferative disorders exclusively in the stem cell transplant setting. The key elements in diagnosis include non-invasive and invasive methods. The former are based on quantitative viral load measurement and imaging with positron emission tomography; the latter with tissue biopsy for histopathology and detection of Epstein-Barr virus. The diagnosis of post-transplant lymphoproliferative disorder can be established on a proven or probable level. Therapeutic strategies include prophylaxis, preemptive therapy and targeted therapy. Rituximab, reduction of immunosuppression and Epstein-Barr virus-specific cytotoxic T-cell therapy are recommended as first-line therapy, whilst unselected donor lymphocyte infusions or chemotherapy are options as second-line therapy; other methods including antiviral drugs are discouraged.
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Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Jurasz University Hospital, Bydgoszcz, Poland
| | - Walter van der Velden
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Christopher P Fox
- Center for Clinical Hematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dan Engelhard
- Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Catherine Cordonnier
- Department of Hematology, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, and University Paris-Est-Créteil, Créteil, France
| | - Per Ljungman
- Karolinska University Hospital, Departments of Hematology and Allogeneic Stem Cell Transplantation, Karolinska Institutet, Division of Hematology, Department of Medicine, Huddinge, Stockholm, Sweden
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23
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Affiliation(s)
- Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University Torun, Bydgoszcz, Poland
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24
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Salmona M, Fourati S, Feghoul L, Scieux C, Thiriez A, Simon F, Resche-Rigon M, LeGoff J. Automated quantification of Epstein-Barr Virus in whole blood of hematopoietic stem cell transplant patients using the Abbott m2000 system. Diagn Microbiol Infect Dis 2016; 85:428-32. [PMID: 27312691 DOI: 10.1016/j.diagmicrobio.2016.04.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 04/17/2016] [Accepted: 04/26/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Accurate quantification of Epstein-Barr virus (EBV) load in blood is essential for the management of post-transplant lymphoproliferative disorders. The automation of DNA extraction and amplification may improve accuracy and reproducibility. We evaluated the EBV PCR Kit V1 with fully automated DNA extraction and amplification on the m2000 system (Abbott assay). METHODOLOGY Conversion factor between copies and international units (IU), lower limit of quantification, imprecision and linearity were determined in a whole blood (WB) matrix. Results from 339 clinical WB specimens were compared with a home-brew real-time PCR assay used in our laboratory (in-house assay). RESULTS The conversion factor between copies and IU was 3.22 copies/IU. The lower limit of quantification (LLQ) was 1000 copies/mL. Intra- and inter-assay coefficients of variation were 3.1% and 7.9% respectively for samples with EBV load higher than the LLQ. The comparison between Abbott assay and in-house assay showed a good concordance (kappa = 0.77). Loads were higher with the Abbott assay (mean difference = 0.62 log10 copies/mL). SIGNIFICANCE The EBV PCR Kit V1 assay on the m2000 system provides a reliable and easy-to-use method for quantification of EBV DNA in WB.
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Affiliation(s)
- Maud Salmona
- Univ Paris Diderot, Pres Sorbone Paris Cité, Inserm U941, APHP, Microbiology laboratory, Hôpital Saint-Louis, Paris, France.
| | - Slim Fourati
- Univ Paris Diderot, Pres Sorbone Paris Cité, Inserm U941, APHP, Microbiology laboratory, Hôpital Saint-Louis, Paris, France
| | - Linda Feghoul
- Univ Paris Diderot, Pres Sorbone Paris Cité, Inserm U941, APHP, Microbiology laboratory, Hôpital Saint-Louis, Paris, France
| | - Catherine Scieux
- Univ Paris Diderot, Pres Sorbone Paris Cité, Inserm U941, APHP, Microbiology laboratory, Hôpital Saint-Louis, Paris, France
| | - Aline Thiriez
- Univ Paris Diderot, Pres Sorbone Paris Cité, Inserm U941, APHP, Microbiology laboratory, Hôpital Saint-Louis, Paris, France
| | - François Simon
- Univ Paris Diderot, Pres Sorbone Paris Cité, Inserm U941, APHP, Microbiology laboratory, Hôpital Saint-Louis, Paris, France
| | - Matthieu Resche-Rigon
- Univ Paris Diderot, Pres Sorbone Paris Cité, Biostatistics Department, APHP, Hôpital Saint-Louis, Paris, France
| | - Jérôme LeGoff
- Univ Paris Diderot, Pres Sorbone Paris Cité, Inserm U941, APHP, Microbiology laboratory, Hôpital Saint-Louis, Paris, France
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25
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Chiereghin A, Prete A, Belotti T, Gibertoni D, Piccirilli G, Gabrielli L, Pession A, Lazzarotto T. Prospective Epstein-Barr virus-related post-transplant lymphoproliferative disorder prevention program in pediatric allogeneic hematopoietic stem cell transplant: virological monitoring and first-line treatment. Transpl Infect Dis 2016; 18:44-54. [DOI: 10.1111/tid.12485] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 09/11/2015] [Accepted: 09/27/2015] [Indexed: 02/07/2023]
Affiliation(s)
- A. Chiereghin
- Operative Unit of Clinical Microbiology; Laboratory of Virology; St. Orsola-Malpighi University Hospital; Bologna Italy
| | - A. Prete
- Pediatric Oncology and Haematology Unit “Lalla Seràgnoli”; Department of Pediatrics; St. Orsola-Malpighi University Hospital; Bologna Italy
| | - T. Belotti
- Pediatric Oncology and Haematology Unit “Lalla Seràgnoli”; Department of Pediatrics; St. Orsola-Malpighi University Hospital; Bologna Italy
| | - D. Gibertoni
- Department of Biomedical and Neuromotor Sciences; Unit of Hygiene and Biostatistics; University of Bologna; Bologna Italy
| | - G. Piccirilli
- Operative Unit of Clinical Microbiology; Laboratory of Virology; St. Orsola-Malpighi University Hospital; Bologna Italy
| | - L. Gabrielli
- Operative Unit of Clinical Microbiology; Laboratory of Virology; St. Orsola-Malpighi University Hospital; Bologna Italy
| | - A. Pession
- Pediatric Oncology and Haematology Unit “Lalla Seràgnoli”; Department of Pediatrics; St. Orsola-Malpighi University Hospital; Bologna Italy
| | - T. Lazzarotto
- Department of Specialised, Experimental, and Diagnostic Medicine; Operative Unit of Clinical Microbiology; Laboratory of Virology; St. Orsola-Malpighi University Hospital; University of Bologna; Bologna Italy
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26
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Burns DM, Tierney R, Shannon-Lowe C, Croudace J, Inman C, Abbotts B, Nagra S, Fox CP, Chaganti S, Craddock CF, Moss P, Rickinson AB, Rowe M, Bell AI. Memory B-cell reconstitution following allogeneic hematopoietic stem cell transplantation is an EBV-associated transformation event. Blood 2015; 126:2665-75. [PMID: 26450987 PMCID: PMC4732759 DOI: 10.1182/blood-2015-08-665000] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/03/2015] [Indexed: 02/07/2023] Open
Abstract
Allogeneic stem cell transplantation (allo-HSCT) provides a unique opportunity to track Epstein-Barr virus (EBV) infection in the context of the reconstituting B-cell system. Although many allo-HSCT recipients maintain low or undetectable levels of EBV DNA posttransplant, a significant proportion exhibit elevated and rapidly increasing EBV loads which, if left untreated, may lead to potentially fatal EBV-associated posttransplant lymphoproliferative disease. Intriguingly, this high-level EBV reactivation typically arises in the first 3 months posttransplant, at a time when the peripheral blood contains low numbers of CD27+ memory cells which are the site of EBV persistence in healthy immunocompetent donors. To investigate this apparent paradox, we prospectively monitored EBV levels and B-cell reconstitution in a cohort of allo-HSCT patients for up to 12 months posttransplant. In patients with low or undetectable levels of EBV, the circulating B-cell pool consisted predominantly of transitional and naive cells, with a marked deficiency of CD27+ memory cells which lasted >12 months. However, among patients with high EBV loads, there was a significant increase in both the proportion and number of CD27+ memory B cells. Analysis of sorted CD27+ memory B cells from these patients revealed that this population was preferentially infected with EBV, expressed EBV latent transcripts associated with B-cell growth transformation, had a plasmablastic phenotype, and frequently expressed the proliferation marker Ki-67. These findings suggest that high-level EBV reactivation following allo-HSCT may drive the expansion of latently infected CD27+ B lymphoblasts in the peripheral blood.
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Affiliation(s)
- David M Burns
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Rose Tierney
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Claire Shannon-Lowe
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jo Croudace
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Charlotte Inman
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Ben Abbotts
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sandeep Nagra
- Centre for Clinical Haematology, University Hospitals Birmingham National Health Service Trust, Birmingham, United Kingdom; and
| | - Christopher P Fox
- Centre for Clinical Haematology, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospitals Birmingham National Health Service Trust, Birmingham, United Kingdom; and
| | - Charles F Craddock
- Centre for Clinical Haematology, University Hospitals Birmingham National Health Service Trust, Birmingham, United Kingdom; and
| | - Paul Moss
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Alan B Rickinson
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Martin Rowe
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Andrew I Bell
- School for Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
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27
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Swartling L, Allard A, Törlen J, Ljungman P, Mattsson J, Sparrelid E. Prolonged outbreak of adenovirus A31 in allogeneic stem cell transplant recipients. Transpl Infect Dis 2015; 17:785-94. [PMID: 26284461 DOI: 10.1111/tid.12443] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/02/2015] [Accepted: 08/02/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND An outbreak of human adenovirus (HAdV) A31 occurred from December 2011 to March 2012 at the Center for Allogeneic Stem Cell Transplantation (CAST), Karolinska University Hospital in Sweden. We analyzed the outbreak, the routes of transmission, and report the medical consequences. METHODS The medical records of all patients admitted to CAST during the outbreak period were studied. Phylogenetic analysis of the patient HAdV strains was performed by sequencing the hexon gene and the more variable E3 gene. RESULTS We identified 9 cases of HAdV A31. Hygiene measures were implemented, but transmission continued for 2 months. All 9 patients had been admitted to the ward, but 2 had no connection in time to other known HAdV A31 cases. DNA sequencing of the patient strains strongly suggested nosocomial transmission. Transplantation was postponed and then cancelled in 1 patient, and 5 patients were treated with cidofovir because of high levels of viremia. In 7 patients, concomitant graft-versus-host disease (GVHD) grade II-V complicated the clinical picture, as it was difficult to distinguish symptoms of GVHD from those of HAdV infection. CONCLUSION An outbreak of HAdV in HSCT recipients can be difficult to control. Although none of the patients had severe disease, the medical consequences were significant. It is possible that unidentified cases with mild symptoms may have caused continuous transmission at the unit. Regular testing of all patients several weeks beyond the last case identified may be an important measure to control transmission.
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Affiliation(s)
- L Swartling
- Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Allard
- Department of Virology, Umeå University, Umeå, Sweden
| | - J Törlen
- Center for Allogeneic Stem Cell Transplantation, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - P Ljungman
- Center for Allogeneic Stem Cell Transplantation, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Hematology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Mattsson
- Center for Allogeneic Stem Cell Transplantation, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - E Sparrelid
- Division of Infectious Diseases, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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28
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Luskin MR, Heil DS, Tan KS, Choi S, Stadtmauer EA, Schuster SJ, Porter DL, Vonderheide RH, Bagg A, Heitjan DF, Tsai DE, Reshef R. The Impact of EBV Status on Characteristics and Outcomes of Posttransplantation Lymphoproliferative Disorder. Am J Transplant 2015; 15:2665-73. [PMID: 25988622 PMCID: PMC5726526 DOI: 10.1111/ajt.13324] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 02/22/2015] [Accepted: 03/14/2015] [Indexed: 01/25/2023]
Abstract
We examined the associations of Epstein-Barr virus (EBV) status with characteristics and outcomes of posttransplantation lymphoproliferative disorder (PTLD) by studying 176 adult solid organ transplant recipients diagnosed with PTLD between 1990 and 2013 (58 [33%] EBV-negative; 118 [67%] EBV-positive). The proportion of EBV-negative cases increased over time from 10% (1990-1995) to 48% (2008-2013) (p < 0.001). EBV-negative PTLD had distinct characteristics (monomorphic histology, longer latency) though high-risk features (advanced stage, older age, high lactate dehydrogenase, central nervous system involvement) were not more common compared to EBV-positive PTLD. In multivariable analysis, EBV negativity was not significantly associated with worse response to initial therapy (adjusted odds ratio, 0.84; p = 0.75). The likelihood of achieving a complete remission (CR) was not significantly different for EBV-negative versus EBV-positive PTLD including when therapy was reduction of immunosuppression alone (35% vs. 43%, respectively, p = 0.60) or rituximab (43% vs. 47%, p = 1.0). EBV negativity was also not associated with worse overall survival (adjusted hazard ratio, 0.91; p = 0.71). Our findings indicate that EBV status is not prognostic or predictive of treatment response in adults with PTLD. The high proportion of EBV-negative disease diagnosed in recent years highlights the need for new strategies for prevention and management of EBV-negative PTLD.
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Affiliation(s)
- Marlise R. Luskin
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel S. Heil
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kay S. Tan
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah Choi
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Edward A. Stadtmauer
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephen J. Schuster
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David L. Porter
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Robert H. Vonderheide
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam Bagg
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel F. Heitjan
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Donald E. Tsai
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ran Reshef
- Division of Hematology and Oncology, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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29
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McKelvie P, Yixing Lai F, Verma A, Bazargan A. Methotrexate-associated EBV-positive CD20-negative diffuse large B-cell lymphoma localized to skin presenting as multiple chronic lower leg ulcers. Leuk Lymphoma 2015; 57:456-460. [PMID: 26110881 DOI: 10.3109/10428194.2015.1049165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Penelope McKelvie
- a Department of Anatomical Pathology , St Vincent's Hospital Melbourne , Fitzroy , VIC , Australia
| | - Francis Yixing Lai
- b Department of Dermatology , St Vincent's Hospital Melbourne , Fitzroy , VIC , Australia
| | - Amit Verma
- b Department of Dermatology , St Vincent's Hospital Melbourne , Fitzroy , VIC , Australia
| | - Ali Bazargan
- c Department of Haematology , St Vincent's Hospital Melbourne , Fitzroy , VIC , Australia
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30
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How I treat posttransplant lymphoproliferative disorders. Blood 2015; 126:2274-83. [PMID: 26384356 DOI: 10.1182/blood-2015-05-615872] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 09/13/2015] [Indexed: 01/13/2023] Open
Abstract
Posttransplant lymphoproliferative disorder (PTLD) is a potentially fatal disorder arising after solid organ transplant (SOT) or hematopoietic stem cell transplant (HSCT). Iatrogenically impaired immune surveillance and Epstein-Barr virus (EBV) primary infection/reactivation are key factors in the pathogenesis. However, current knowledge on all aspects of PTLD is limited due to its rarity, morphologic heterogeneity, and the lack of prospective trials. Furthermore, the broad spectrum of underlying immune disorders and the type of graft represent important confounding factors. Despite these limitations, several reviews have been written aimed at offering a guide for pathologists and clinicians in diagnosing and treating PTLD. Rather than providing another classical review on PTLD, this "How I Treat" article, based on 2 case reports, focuses on specific challenges, different perspectives, and novel insights regarding the pathogenesis, diagnosis, and treatment of PTLD. These challenges include the wide variety of PTLD presentation (making treatment optimization difficult), the impact of EBV on pathogenesis and clinical behavior, and the controversial treatment of Burkitt lymphoma (BL)-PTLD.
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31
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Sanz J, Andreu R. Epstein-Barr virus-associated posttransplant lymphoproliferative disorder after allogeneic stem cell transplantation. Curr Opin Oncol 2015; 26:677-83. [PMID: 25162331 DOI: 10.1097/cco.0000000000000119] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Epstein-Barr virus (EBV)-associated posttransplant lymphoproliferative disorder is an increasingly life-threatening complication after allogeneic stem cell transplantation with the use of more complex transplant procedures. RECENT FINDINGS Reduced intensity conditioning regimens in combination with in-vivo or ex-vivo T-cell depletion are particularly important risk factors. Prospective monitoring of EBV viremia by real-time quantitative polymerase-chain reaction (PCR) should be performed after high-risk allogeneic stem cell transplantation. However, lack of standardization and concerns about sensitivity and low positive-predictive value challenge the interpretation of PCR monitoring. Preemptive treatment is feasible and can reduce EBV-related mortality but may lead to overtreatment in some patients. Readily available rituximab and methods of adoptive transfer of T-cells are valuable tools. Rituximab is probably the most attractive agent showing the most robust data in this setting. Rituximab seems to offer a good balance between efficacy and toxicity for the treatment of established EBV-associated posttransplant lymphoproliferative disorder. But most often there is a need to combine with adoptive immunotherapy with T-cells to maintain long-term disease control, with either simple unmanipulated donor lymphocyte infusion or more specific and complex adoptive EBV-specific cytotoxic T-cells. SUMMARY EBV-associated posttransplant lymphoproliferative disorder can often be prevented or treated, especially in earlier stages. The specific role and timing of the different treatment strategies need to be defined.
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Affiliation(s)
- Jaime Sanz
- Department of Hematology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Fungal and viral infections after allogeneic hematopoietic transplantation from unrelated donors in adults: improving outcomes over time. Bone Marrow Transplant 2014; 50:274-81. [PMID: 25347007 DOI: 10.1038/bmt.2014.229] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 08/20/2014] [Accepted: 08/22/2014] [Indexed: 11/09/2022]
Abstract
Umbilical cord blood (CB) is increasingly used as an alternative source of stem cells in adult unrelated transplantation. Although registry studies report similar overall outcomes in comparison with BM/PB, comparative studies focusing on severe infections and infection-RM (IRM) with a long follow-up are scarce. A total of 434 consecutive unrelated transplants (1997-2009) were retrospectively analyzed to compare overall outcomes, incidence and risk factors of severe viral and invasive fungal infections in CB (n=65) vs BM/PB recipients (n=369). The 5-year OS was 38 vs 43%, respectively (P=0.2). CB transplantation (CBT) was associated with a higher risk of invasive aspergillosis (100-days-cumulative incidence 16 vs 6%, P=0.04) and CMV infection without differences in RM. No statistically significant differences were found regarding NRM (NRM of 38% in CB vs 37% in BM/PB at 1 year) nor IRM (30% in CB vs 27% in BM/PB at 1 year). In the overall population, NRM and IRM improved in more recent years. In adults who receive a single CBT, the risk of severe infections is increased when compared with unrelated BM/PB recipients, but mortality from infections is similar, leading to similar NRM and survival.
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Han SB, Bae EY, Lee JW, Jang PS, Lee DG, Chung NG, Jeong DC, Cho B, Lee SJ, Kang JH, Kim HK. Features of Epstein-Barr virus reactivation after allogeneic hematopoietic cell transplantation in Korean children living in an area of high seroprevalence against Epstein-Barr virus. Int J Hematol 2014; 100:188-99. [PMID: 24981711 DOI: 10.1007/s12185-014-1613-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 06/08/2014] [Accepted: 06/09/2014] [Indexed: 11/25/2022]
Abstract
The present study was conducted to investigate Epstein-Barr virus (EBV) reactivation after hematopoietic cell transplantation (HCT) in Korean children living in an area of a high seroprevalence against EBV and to determine the impact of recipient age on EBV reactivation. Medical records of 248 children and adolescents who had received allogeneic HCT were retrospectively reviewed. The trends of EBV reactivation and post-transplant lymphoproliferative disorders (PTLDs) were evaluated and compared between younger (≤10 years old) and older (11-20 years old) groups. EBV reactivation occurred in 177 cases (71.4 %) and high-level EBV reactivation, defined as a virus DNA titer of 300,000 copies/mL or higher, occurred in 21 cases (8.5 %). PTLD was diagnosed in five cases (2.0 %), and one of these patients died. The EBV reactivation rate was not significantly different between the two age groups; however, high-level reactivation and PTLD were more significantly frequent in the older than in the younger group (P = 0.030 and P = 0.026, respectively). In conclusion, older children and adolescents are more likely to experience high-level EBV reactivation and PTLDs, and higher EBV DNA titers than those previously reported may be a predictor of PTLD in areas with a high seroprevalence against EBV.
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Affiliation(s)
- Seung Beom Han
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 137-701, Republic of Korea
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Wikell H, Ponandai-Srinivasan S, Mattsson J, Gertow J, Uhlin M. Cord blood graft composition impacts the clinical outcome of allogeneic stem cell transplantation. Transpl Infect Dis 2014; 16:203-12. [DOI: 10.1111/tid.12182] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 06/05/2013] [Accepted: 07/15/2013] [Indexed: 11/28/2022]
Affiliation(s)
- H. Wikell
- Division of Therapeutic Immunology; Karolinska Institutet; Stockholm Sweden
- Department of Clinical Immunology and Transfusion Science; Karolinska University Hospital; Stockholm Sweden
| | | | - J. Mattsson
- Division of Therapeutic Immunology; Karolinska Institutet; Stockholm Sweden
- Center for Allogeneic Stem Cell Transplantation; Karolinska University Hospital; Stockholm Sweden
| | - J. Gertow
- Division of Therapeutic Immunology; Karolinska Institutet; Stockholm Sweden
- Center for Allogeneic Stem Cell Transplantation; Karolinska University Hospital; Stockholm Sweden
| | - M. Uhlin
- Division of Therapeutic Immunology; Karolinska Institutet; Stockholm Sweden
- Center for Allogeneic Stem Cell Transplantation; Karolinska University Hospital; Stockholm Sweden
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EBV-associated post-transplant lymphoproliferative disorder following in vivo T-cell-depleted allogeneic transplantation: clinical features, viral load correlates and prognostic factors in the rituximab era. Bone Marrow Transplant 2013; 49:280-6. [PMID: 24212561 DOI: 10.1038/bmt.2013.170] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 08/11/2013] [Accepted: 09/11/2013] [Indexed: 11/08/2022]
Abstract
EBV-associated post-transplant lymphoproliferative disease (PTLD) following Alemtuzumab-based allo-SCT is a relatively uncommon and challenging clinical problem but has not received detailed study in a large cohort. Quantitative-PCR (qPCR) monitoring for EBV reactivation post allo-SCT is now commonplace but its diagnostic and predictive value remains unclear. Sixty-nine patients with PTLD following Alemtuzumab-based allo-SCT were studied. Marked clinicopathological heterogeneity was evident; lymphadenopathy was frequently absent, whereas advanced extranodal disease was common. The median viral load at clinical presentation was 49 300 copies/mL (50-65 200 000 copies/mL) and, notably, 23% and 45% of cases, respectively, had 10 000 and 40 000 copies/mL. The overall response rate to rituximab as first-line therapy was 70%. For rituximab failures, chemotherapy was ineffectual but DLIs were successful. A four-parameter prognostic index predicted response to therapy (OR 0.30 (0.12-0.74); P=0.009] and PTLD mortality (hazard ratio (HR) 1.81 (1.12-2.93) P=0.02) on multivariate analysis. This is the largest detailed series of EBV-associated PTLD after allo-SCT. At clinical presentation, EBV-qPCR values are frequently below customary thresholds for pre-emptive therapy, challenging current paradigms for monitoring and intervention. A four-point score identifies a proportion of patients at risk of rituximab-refractory disease for whom alternative therapy is needed.
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Uhlin M, Wikell H, Sundin M, Blennow O, Maeurer M, Ringden O, Winiarski J, Ljungman P, Remberger M, Mattsson J. Risk factors for Epstein-Barr virus-related post-transplant lymphoproliferative disease after allogeneic hematopoietic stem cell transplantation. Haematologica 2013; 99:346-52. [PMID: 24056821 DOI: 10.3324/haematol.2013.087338] [Citation(s) in RCA: 132] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation is a successful treatment for hematologic malignancies and a variety of genetic and metabolic disorders. In the period following stem cell transplantation, the immune-compromised milieu allows opportunistic pathogens to thrive. Epstein-Barr virus-associated post-transplant lymphoproliferative disease can be a life-threatening complication for transplanted patients because of suppressed T-cell-mediated immunity. We analyzed possible risk factors associated with post-transplant lymphoproliferative disease in a cohort of over 1,000 patients. The incidence of post-transplant lymphoproliferative disease was 4%. Significant risk factors identified by multivariate analysis were: human leukocyte antigen-mismatch (P<0.001), serological Epstein-Barr virus mismatch recipient-/donor+ (P<0.001), use of reduced intensity conditioning (P=0.002), acute graft-versus-host disease grade II to IV (P=0.006), pre-transplant splenectomy (P=0.008) and infusion of mesenchymal stromal cells (P=0.015). The risk of post-transplant lymphoproliferative disease has increased in more recent years, from less than 2% before 1998 to more than 6% after 2011. Additionally, we show that long-term survival of patients with post-transplant lymphoproliferative disease is poor despite initial successful treatment. The 3-year survival rate among the 40 patients with post-transplant lymphoproliferative disease was 20% as opposed to 62% among patients without post-transplant lymphoproliferative disease (P<0.001). The study identifies patients at risk of post-transplant lymphoproliferative disease after transplantation in need of pre-emptive measures.
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Friis A, Akerlund B, Christensson B, Gyllensten K, Aleman A, Zou JZ, Ernberg I. Epstein Barr virus DNA analysis in blood predicts disease progression in a rare case of plasmablastic lymphoma with effusion. Infect Agent Cancer 2013; 8:28. [PMID: 23880011 PMCID: PMC3726497 DOI: 10.1186/1750-9378-8-28] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 07/17/2013] [Indexed: 12/12/2022] Open
Abstract
Background In HIV-1-infected patients a long lasting CD4+ cell decline influences the host-EBV balance and thereby increases the risk for EBV related malignancies. In spite of a world-wide access to combination antiretroviral therapy (cART) there are still a considerable number of HIV-1-infected patients who will develop severe immunodeficiency. These undiagnosed HIV-1 infected patients, so called late testers, demonstrate an increased lymphoma risk, compared to patients diagnosed early. Consecutive individual screening for EBV DNA-load in late testers might be a useful predictor of emerging EBV-malignancy. Methods Patient biopsies and ascites were analyzed morphologically, by immuncyto-histochemistry and in-situ hybridization. Viral DNA and RNA load were quantified by PCR. Cell lines from primary tumor and from ascites, were established in vitro and further analyzed. Result We here report on a case of EBV-positive lymphoma in an AIDS patient, first presenting with pleural effusion and ascites and was thus initially considered a primary effusion lymphoma (PEL) but was later diagnosed as a plasmablastic lymphoma (PBL). The patient had responded to cART with undetectable HIV-RNA and increased CD4 cell count one year prior to lymphoma presentation. At the time of lymphoma diagnosis the HIV-RNA values were <50 RNA-copies per mL blood (undetectable) and the CD4-positive cell count 170 ×106/L. The lymphoma was CD45-negative and weakly CD22- and CD30-positive. The patient had a history of Kaposi sarcoma and HHV-8 seropositivity. The lymphoma biopsies, and three cell lines derived on different occasions from the tumor cell effusion, were all EBV-positive but HHV-8 negative. A noticeable EBV-DNA load decline was observed during the remission of the lymphoma following CHOP-therapy. The EBV-DNA load increased dramatically at the time of recurrence. Conclusion EBV DNA load might be useful in monitoring the effect of lymphoma treatment as well as in estimating the risk of EBV-associated lymphoma in HIV-1 infected patients with pronounced immunosuppression.
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Affiliation(s)
- Anna Friis
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
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38
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EBV-induced post transplant lymphoproliferative disorders: a persisting challenge in allogeneic hematopoetic SCT. Bone Marrow Transplant 2013; 49:163-7. [PMID: 23832092 DOI: 10.1038/bmt.2013.96] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 06/04/2013] [Indexed: 12/21/2022]
Abstract
EBV-induced post transplantation lymphoproliferative disorder (EBV-PTLD) is a life-threatening complication after allogeneic hematopoietic cell transplantation. Profound T-cell depletion of the allograft represents a major risk factor for EBV-PTLD. With regard to the increasing use of alternative stem cell sources such as cord blood or purified haploidentical stem cell grafts both associated with impaired immune reconstitution, the frequent occurrence of EBV-PTLD demands particular vigilance on laboratory changes and early symptoms. Here we have summarized today's knowledge about EBV-PTLD in a comprehensive review explaining the underlying mechanisms of EBV-based transformation, EBV-PTLD development, clinical presentation, incidence, diagnosis, screening, therapy and prognosis. In this context, we emphasize on the necessity of regularly applied screening tools and pre-emptive treatment strategies including anti-CD20 Abs particularly in high-risk patients to avoid disease progression to malignant lymphoma. Although EBV-PTLD has always been associated with a high mortality rate, novel immunotherapeutic approaches such as the transfer of EBV-specific T cells nowadays offer improved chances of disease control even at late stages.
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Liu Q, Xuan L, Liu H, Huang F, Zhou H, Fan Z, Zhao K, Wu M, Xu L, Zhai X, Zhang F, Liu C, Sun J, Huang X. Molecular monitoring and stepwise preemptive therapy for Epstein-Barr virus viremia after allogeneic stem cell transplantation. Am J Hematol 2013; 88:550-5. [PMID: 23564232 DOI: 10.1002/ajh.23452] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Revised: 03/05/2013] [Accepted: 04/02/2013] [Indexed: 01/11/2023]
Abstract
The optimal preemptive therapy for Epstein-Barr virus (EBV)-associated diseases remains under discussion. We developed a stepwise preemptive therapy (antiviral agents and reduction of immunosuppressants [RI] followed by rituximab) for EBV viremia, based on duration of EBV viremia and changes of viral loads. The blood EBV-DNA loads were regularly monitored by quantitative real-time polymerase chain reaction in 251 recipients undergoing allogeneic stem cell transplantation. The 3-year cumulative incidence of EBV viremia and EBV-associated diseases were 31.1% ± 3.1% and 15.6% ± 2.5%, which rose steeply with greater numbers of major risk factors. Of the 64 patients undergoing first-step preemption, 24 achieved complete response (CR) and 40 showed no response, including 25 progressing to EBV-associated diseases. The effective rates of antiviral agents and RI plus antiviral agents were 2/16 and 22/48 (P = 0.017). Fourteen achieved CR and one progressed to lymphoproliferative disease in the 15 patients undergoing rituximab preemption. Of the 26 patients progressing to EBV-associated diseases during preemptive therapy, 20 obtained CR in the 23 cases with rituximab-based treatments. The preemptive efficacy of RI plus antiviral agents was correlated with the numbers of major risk factors (rs = -0.298; P = 0.04). B-cell reconstitution was significantly delayed for at least 6 months in patients with rituximab preemption. The risk of herpesvirus infection was similar in patients who showed effective progress to first-step and rituximab preemption (P = 0.094). RI plus antiviral agents could be given priority to low-risk patients, whereas more frequent monitoring of blood EBV-DNA and earlier preemptive rituximab should be advocated in high-risk patients.
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Affiliation(s)
- Qifa Liu
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Hongsheng Zhou
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Ke Zhao
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Meiqing Wu
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Lanping Xu
- Institute of Hematology; Peking University People's Hospital; Beijing 100044 China
| | - Xiao Zhai
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Fuhua Zhang
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Can Liu
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital; Southern Medical University; Guangzhou 510515 China
| | - Xiaojun Huang
- Institute of Hematology; Peking University People's Hospital; Beijing 100044 China
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van der Velden WJFM, Mori T, Stevens WBC, de Haan AFJ, Stelma FF, Blijlevens NMA, Donnelly JP. Reduced PTLD-related mortality in patients experiencing EBV infection following allo-SCT after the introduction of a protocol incorporating pre-emptive rituximab. Bone Marrow Transplant 2013; 48:1465-71. [PMID: 23749107 DOI: 10.1038/bmt.2013.84] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/27/2013] [Accepted: 04/29/2013] [Indexed: 01/15/2023]
Abstract
The mortality associated with post-transplant lymphoproliferative disorder (PTLD) induced by EBV infection can be reduced by monitoring EBV by polymerase-chain-reaction and rituximab given pre-emptively. We performed a retrospective analysis of the risk factors for the occurrence of EBV infection/disease and EBV-related mortality among 273 consecutive recipients of a T-cell-depleted allo-SCT during two periods: (a) before the implementation of a comprehensive protocol (2006-2008) and (b) afterwards (2009-2011). EBV infection was detected in 61 (22%) cases, and 28 cases were considered to have had EBV disease. Treatment with antithymocyte globulin was the most important risk factor (odds ratio (OR) 2.4; 95% confidence interval (CI) 1.3-4.2, P=0.001). After implementation of the protocol, in patients experiencing EBV infection, pre-emptive therapy was started more often and sooner (median 3 vs 6 days, P=0.002). Moreover, there were fewer cases of monomorphic PTLD (4/33 (12%) vs 11/28 (39%), P=0.01), and the EBV-related mortality was lower for patients experiencing EBV infection (2/33 (6%) vs 8/28 (29%), OR 0.2; 95% CI 0.05-0.9, P=0.03). The EBV protocol proved feasible and resulted in faster initiation of pre-emptive therapy, the diagnosis in an earlier stage of EBV disease, and decreased EBV-related mortality.
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Affiliation(s)
- W J F M van der Velden
- 1] Department of Haematology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands [2] Nijmegen Institute for Infection, Inflammation and Immunity (N4i), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Bamoulid J, Courivaud C, Coaquette A, Chalopin JM, Gaiffe E, Saas P, Ducloux D. Subclinical Epstein-Barr virus viremia among adult renal transplant recipients: incidence and consequences. Am J Transplant 2013; 13:656-62. [PMID: 23331474 DOI: 10.1111/ajt.12009] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 10/01/2012] [Accepted: 10/08/2012] [Indexed: 01/25/2023]
Abstract
The natural history and clinical significance of posttransplant Epstein-Barr virus (EBV) infection remain largely unknown. The aims of this study are to describe the incidence, risk factors and consequences of EBV infection after kidney transplantation. A total of 383 consecutive patients having received a kidney transplant between January 2002 and December 2010 were included. EBV polymerase chain reaction (PCR) was performed every 2 weeks for 3 months, and every 4 weeks for the next 9 months. A total of 155 of the 383 patients (40%) had at least one positive viremia during the first year posttransplant. The median time to viremia was day 31 posttransplant (14-329). A total of 73 (47%) had EBV viremia > 10(3) log and 23 (15%) had positive viremia for more than 6 months. EBV D+/R- patients (12/18 (67%) versus 143/365 (39%), p = 0.02) and those having received antithymocyte globulins (ATG) (54% vs. 35%; p<0.001) were more likely to develop EBV infection. EBV infection (hazard ratio [HR], 3.03; 95% confidence interval [CI], 1.72-8.29; p = 0.01) was associated with the occurrence of opportunistic infections. A positive EBV PCR during the first 6 months posttransplant was associated with graft loss (HR, 3.04; 95% CI, 1.36-6.79; p = 0.014). EBV reactivation is frequent after transplantation and reflects overimmunosuppression. Prospective studies should examine the association between EBV and graft loss.
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Wiernik PH, Goldman JM, Dutcher JP, Kyle RA. Prevention of Infections in Patients with Hematological Malignancies. NEOPLASTIC DISEASES OF THE BLOOD 2013. [PMCID: PMC7121527 DOI: 10.1007/978-1-4614-3764-2_51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Infection is a frequent complication and a leading cause of morbidity and mortality in patients with hematological malignancies. Problems associated with the management of infections in these patients include difficulties in early diagnosis because the clinical signs of infection are subtle, the low performance of diagnostic tests, and suboptimal response to treatment because recovery of host defenses is a key factor for resolution of infection. Preventing these infections relies on infection control measures and antimicrobial chemoprophylaxis. While infection control measures are safe (but not always effective), the use of antimicrobial agents for prophylaxis of infection is not devoid of problems. Its wide use may increase the possibility of the development of resistance, select for resistant organisms, and increase toxicity and cost. Therefore, any attempt to administer an antimicrobial agent should be accompanied by a reflection of the potential benefits and risks of prophylaxis.
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Affiliation(s)
- Peter H. Wiernik
- Beth Israel Hospital, Cancer Center, St. Lukes-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - John M. Goldman
- , Department of Hematology, Imperial College of London, Du Cane Road 150, London, W12 0NN United Kingdom
| | - Janice P. Dutcher
- Continuum Cancer Centers, Department of Medicine, St. Luke's-Roosevelt Hospital Center, 10th Avenue 1000, New York, 10019 New York USA
| | - Robert A. Kyle
- , Division of Hematology, Mayo Clinic, First Street SW. 200, Rochester, 55905 Minnesota USA
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Gequelin LCF, Riediger IN, Nakatani SM, Biondo AW, Bonfim CM. Epstein-Barr virus: general factors, virus-related diseases and measurement of viral load after transplant. Rev Bras Hematol Hemoter 2012; 33:383-8. [PMID: 23049344 PMCID: PMC3415781 DOI: 10.5581/1516-8484.20110103] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 05/19/2011] [Indexed: 02/06/2023] Open
Abstract
The Epstein-Barr virus is responsible for infectious mononucleosis syndrome and is also closely associated to several types of cancer. The main complication involving Epstein-Barr virus infection, both in recipients of hematopoietic stem cells and solid organs, is post-transplant lymphoproliferative disease. The importance of this disease has increased interest in the development of laboratory tools to improve post-transplant monitoring and to detect the disease before clinical evolution. Viral load analysis for Epstein-Barr virus through real-time polymerase chain reaction is, at present, the best tool to measure viral load. However, there is not a consensus on which sample type is the best for the test and what is its predictive value for therapeutic interventions.
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Strategy of pre-emptive management of Epstein-Barr virus post-transplant lymphoproliferative disorder after stem cell transplantation: results of European transplant centers survey. Contemp Oncol (Pozn) 2012; 16:338-40. [PMID: 23788905 PMCID: PMC3687436 DOI: 10.5114/wo.2012.30064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 03/12/2012] [Accepted: 05/07/2012] [Indexed: 01/31/2023] Open
Abstract
Aim of the study Epstein-Barr virus-related post-transplant lymphoproliferative disorder (EBV-PTLD) is a serious complication after stem cell transplantation (SCT) and the number of patients at risk is increasing over time. Available data do not reflect general practice of diagnosis and treatment of this complication. Material and methods In 2009 a survey on management of the pre-emptive strategy of EBV infection was done and results from 74 European transplant centers were registered and analyzed. Results Regular monitoring for EBV after SCT is done by most of the participating centers (73%). In 68% of them the monitoring is performed in all alloSCT patients, while in remaining centers it is done in high-risk patients only. Quantitative EBV-DNA is performed in 97% of centers, mainly in whole blood (78%) and usually repeated once a week (60.9%). The monitoring for EBV reactivation is performed for a period of 3 months (37%) to 6 months (30%) or adjusted to risk factors (20%). Rituximab as a pre-emptive therapy for EBV-PTLD is routinely administered in 80% of responding centers. The number of EBV-DNA copies as an indicator for pre-emptive therapy with rituximab varies between the centers. Conclusions The strategy of management of EBV infection exists in most of the responding centers. Different approaches regarding indications for preemptive therapy are seen between centers: rituximab is administered as pre-emptive therapy in most participating transplant centers.
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Pérez JL, Ayats J, de Oña M, Pumarola T. The role of the clinical microbiology laboratory in solid organ transplantation programs. Enferm Infecc Microbiol Clin 2012; 30 Suppl 2:2-9. [PMID: 22542029 DOI: 10.1016/s0213-005x(12)70076-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Infections remain a major complication of solid organ transplantation. For this reason, the clinical microbiology laboratory plays a key role in the success of transplant programs, which must have the support of a qualified laboratory, both technically and professionally. Transplant programs strongly condition the structure and functionality of microbiology laboratories, but at the same time, benefit greatly from the knowledge generated from these programs. The laboratory must make a special effort to implement rapid methods that can respond to the broad spectrum of potential pathogens in solid organ transplant patients. The integration of microbiologists in multidisciplinary teams is highly recommended, as only then can they obtain the highest quality and efficiency in the diagnostic process. This article provides an updated review of the techniques to be used once transplantation has occurred. The role of the microbiologist is also crucial in the pretransplant period, as good microbiological candidate evaluation at this time strongly conditions the success of the transplantation program.
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Affiliation(s)
- José L Pérez
- Service of Microbiology, Hospital Universitario Son Espases, Palma de Mallorca, Spain.
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Christopeit M, Janssen N, Weber T, Bacher U, Lautenschläger C, Oehme A, Kekulé AS, Schmoll HJ. Cyclosporine area under the curve after allogeneic hematopoietic stem cell transplantation is an indicator of Epstein-Barr virus DNAemia. Leuk Lymphoma 2012; 54:133-7. [PMID: 22721496 DOI: 10.3109/10428194.2012.705001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Epstein-Barr virus (EBV) DNAemia and reactivation is a typical complication after allogeneic hematopoietic stem cell transplantation (HSCT). The degree of immunosuppression is closely linked to the risk of developing EBV DNAemia. An association of cyclosporine levels with EBV DNAemia has not been interrogated. Here, we analyzed cyclosporine levels in 58 patients after allogeneic HSCT. We discovered a wide range of cyclosporine trough level variation in the individual patient (median coefficient of variation [CV] 0.29, range 0.19-0.78). To overcome this high intra-individual variation in serum trough levels of cyclosporine, we calculated respective areas under the curve (AUC) and performed correlations with EBV DNAemia in 28 stem cell recipients at increased risk for EBV DNAemia. This resulted in a significant association of high cyclosporine AUC (> 6000 ng/mL × days) with EBV DNAemia after day 30 (relative risk [RR] 6.067, 95% confidence interval [CI] 1.107-33.238, p = 0.038). Conversely, mean cyclosporine values (threshold 200 ng/mL) between days 0 and 30 were not found to correlate with EBV DNAemia after day 30. Furthermore, CD3 + CD8 + graft content was inversely correlated with EBV DNAemia after day 30. These findings might establish a clinical role for the AUC of cyclosporine.
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Affiliation(s)
- Maximilian Christopeit
- Department of Oncology and Hematology, University Hospital/Medical Faculty, University Cancer Center Hamburg, Hamburg, Germany.
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Breuer S, Rauch M, Matthes-Martin S, Lion T. Molecular diagnosis and management of viral infections in hematopoietic stem cell transplant recipients. Mol Diagn Ther 2012; 16:63-77. [PMID: 22497528 DOI: 10.1007/bf03256431] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Viral infections after allogeneic hematopoietic stem cell transplantation (HSCT) are important complications associated with high morbidity and mortality. In this setting, reactivations of persisting latent viral pathogens from donor and/or recipient cells play a central role whereas the sterile environment of transplant units renders new infections less likely. The viruses currently regarded as most relevant in the HSCT setting include particularly the herpes virus family--specifically cytomegalovirus (CMV), Epstein-Barr virus (EBV), and human herpesvirus 6 (HHV-6)--as well as human adenoviruses (AdVs) and the polyoma virus BK (BKV). Timely detection and monitoring of virus copy numbers are prerequisites for successful preemptive treatment approaches. Pre- and post-transplant surveillance by sensitive and quantitative molecular methods has therefore become an essential part of the diagnostic routine. In this review, we discuss diagnostic aspects and the clinical management of the most important viral infections in HSCT recipients, with a focus on pediatric patients.
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Affiliation(s)
- Sabine Breuer
- Department of Pediatric Stem Cell Transplantation, St. Anna Childrens Hospital, Medical University of Vienna, Vienna, Austria
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48
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Xuan L, Huang F, Fan Z, Zhou H, Zhang X, Yu G, Zhang Y, Liu C, Sun J, Liu Q. Effects of intensified conditioning on Epstein-Barr virus and cytomegalovirus infections in allogeneic hematopoietic stem cell transplantation for hematological malignancies. J Hematol Oncol 2012; 5:46. [PMID: 22856463 PMCID: PMC3422173 DOI: 10.1186/1756-8722-5-46] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 07/25/2012] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Intensified conditioning regimens (increasing the intensity of standard myeloablative conditioning) for hematological malignancies in allogeneic hematopoietic stem cell transplantation (allo-HSCT) could reduce the relapse rate of the underlying disease, but it might simultaneously increase the transplant-related mortality including the mortality of infections. To explore whether intensified conditioning affected Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections, 185 patients undergoing allo-HSCT were enrolled. METHODS A total of 104 cases received standard and 81 intensified conditioning. Cyclosporine A (CsA) withdrawal and/or donor lymphocyte infusion (DLI) were conducted in high-risk patients. The EBV-DNA and CMV-DNA levels of blood were monitored regularly by quantitative real-time polymerase chain reaction (RQ-PCR) and immune reconstitution of recipients were analyzed by flow cytometry. RESULTS The 3-year cumulative incidence of EBV viremia, EBV-associated diseases and mortality of EBV-associated diseases were 25.3% ± 4.6%, 10.5% ± 3.4% and 0.0% ± 0.0% in the standard group, compared with 45.6% ± 6.5%, 26.0% ±5.3% and 7.3% ± 3.1% in the intensified group (P = 0.002, P = 0.002, P = 0.008). The 3-year cumulative incidence of CMV viremia and CMV-associated diseases, mortality of CMV-associated diseases and incidence of bacterial and fungal infections were similar between the two groups (P = 0.855, P = 0.581, P = 0.933, P = 0.142, P = 0.182, respectively). Multivariate analysis showed that intensified conditioning was one of the risk factors for EBV viremia and EBV-associated diseases (P = 0.037, P = 0.037), but it had no effects on CMV infections. The percentage of CD4+ T cells and CD4+/CD8+ ratio at 3 months post-transplantation were lower in the intensified group (P = 0.032, P = 0.022). The 3-year OS and DFS in the standard group were 62.2% ± 5.8% and 60.6% ± 5.6%, compared with 51.6% ± 6.2% and 51.1% ± 5.9% in the intensified group (P = 0.029, P = 0.063). CONCLUSIONS Intensified conditioning represents a promising approach for high-risk hematological malignancies, although it affects early immune reconstitution of recipients and increases the incidence and mortality of EBV infections.
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Affiliation(s)
- Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Hongsheng Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xian Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Guopan Yu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yu Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Can Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
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49
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Uhlin M, Gertow J, Uzunel M, Okas M, Berglund S, Watz E, Brune M, Ljungman P, Maeurer M, Mattsson J. Rapid salvage treatment with virus-specific T cells for therapy-resistant disease. Clin Infect Dis 2012; 55:1064-73. [PMID: 22806594 DOI: 10.1093/cid/cis625] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Viral infections are major complications after allogeneic hematopoietic stem cell transplantation (HSCT). During posttransplant immunosuppression the regular T-cell control is compromised. Even if treatment strategies against infections caused by herpes viruses such as cytomegalovirus, Epstein-Barr virus, and adenovirus have improved, the mortality rate is still considerable. If primary antiviral therapy fails or cannot be tolerated, adoptive therapy with virus-specific cytotoxic T cells (CTL) can be utilized. METHODS In this study, we used virus-specific CTLs to treat 8 patients suffering from severe viral infections after allogeneic HSCT. Using positive selection with HLA multimers and magnetic beads, we isolated CTLs from both frozen donor material as well as third-party donors within hours. RESULTS At 90 days after CTL infusions 7 out of 8 patients were still living. CTLs infused from third-party donors were detected in 5 of 6 patients up to 76 days after infusion. No graft-versus-host disease associated with CTL infusions was observed. CONCLUSIONS Our separation approach offers a rapid alternative for adoptive CTL therapy if primary antiviral treatment strategies fail. Because no prolonged expansion steps are needed, this method may be used for early treatment of patients suffering from life-threatening infectious complications.
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Affiliation(s)
- Michael Uhlin
- Therapeutic Immunology Unit, Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden.
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50
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Cukuranovic J, Ugrenovic S, Jovanovic I, Visnjic M, Stefanovic V. Viral infection in renal transplant recipients. ScientificWorldJournal 2012; 2012:820621. [PMID: 22654630 PMCID: PMC3357934 DOI: 10.1100/2012/820621] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2011] [Accepted: 01/10/2012] [Indexed: 12/18/2022] Open
Abstract
Viruses are among the most common causes of opportunistic infection after transplantation. The risk for viral infection is a function of the specific virus encountered, the intensity of immune suppression used to prevent graft rejection, and other host factors governing susceptibility. Although cytomegalovirus is the most common opportunistic pathogen seen in transplant recipients, numerous other viruses have also affected outcomes. In some cases, preventive measures such as pretransplant screening, prophylactic antiviral therapy, or posttransplant viral monitoring may limit the impact of these infections. Recent advances in laboratory monitoring and antiviral therapy have improved outcomes. Studies of viral latency, reactivation, and the cellular effects of viral infection will provide clues for future strategies in prevention and treatment of viral infections. This paper will summarize the major viral infections seen following transplant and discuss strategies for prevention and management of these potential pathogens.
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Affiliation(s)
| | | | - Ivan Jovanovic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
| | - Milan Visnjic
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
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