Pre-Transplant Platelet Refractoriness and Alternative Donors Are Associated With Cytomegalovirus Retinitis in Hematopoietic Stem Cell Transplantation for Severe Aplastic Anemia

Epidemiology, clinical outcomes, and treatment patterns of cytomegalovirus infection after allogeneic hematopoietic stem cell transplantation in China: a scoping review and meta-analysis

Introduction

Cytomegalovirus (CMV) infection poses a significant threat to individuals undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), potentially resulting in substantial morbidity and mortality. This review summarized the epidemiology, clinical outcomes, and treatment patterns of CMV infection among allo-HSCT recipients in China.

Methods

PubMed, EMBASE, the Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang and Chinese Biomedical Literature Database (CBM) were systematically searched from 2013 to March 2023. All analyses were performed using R 4.1.1 software with a random effects model.

Results

Fifty-six studies, which included 13,882 patients, were reviewed. The pooled overall incidence of CMV infection was 49.99% [95% confidence interval (CI) 43.72-56.26%]. Among post allo-HSCT recipients with CMV infection, 32.03% (95% CI 22.93-41.12%) developed refractory CMV infection. The overall incidence of CMV disease was 13.30% (95% CI 8.99-19.66%). The pooled all-cause mortality rate was 29.25% (95% CI 17.96-40.55%) and the CMV-related mortality rate was 3.46% (95% CI 1.19-5.73%). Results demonstrate that management of CMV has mainly focused on pre-emptive therapy due to the treatment-limiting toxicity of anti-CMV agents. Additionally, CMV infection is continuing to occur after the discontinuation of prophylaxis, highlighting the unmet need for a more effective treatment without treatment-limiting toxicities.

Conclusion

This review underscores the urgent need for improved therapeutic strategies to effectively manage cytomegalovirus infection in allo-HSCT recipients, particularly in light of the high incidence and associated morbidity, as well as the limitations of current treatment options.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024513908, identifier: CRD42024513908.

Risk Factors of Cytomegalovirus Retinitis Occurrence After Allogeneic Hematopoietic Stem Cell Transplantation

PURPOSE

To explore the potential risk factors for the occurrence of human cytomegalovirus (HCMV) retinitis (CMVR) in allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients.

METHODS

This is a retrospective, nested case-control study conducted in hematological patients with CMVR who underwent allo-HSCT. Patients diagnosed with CMVR after allo-HSCT were included as the case group, and those without CMVR were matched by a ratio of 1:2 and were recruited as controls. We selected 19 pre- and post-transplant indicators for univariate analysis between the cases and controls, and then Logistic regression analysis was used to calculate the odds ratio (OR) and 95% confidence intervals (CI) for exploration of risk factors of the CMVR occurrence.

RESULTS

A total of 1308 allo-HSCT patients from January 1, 2020 to July 31, 2023 were analyzed, and 27 patients were diagnosed CMVR with a median onset time of 222 days after transplantation. In univariate analysis, donors of stem cells source, HLA-match types (including matched sibling donor, haploidentical donor, and unrelated donor), post-transplant Epstein-Barr virus (EBV) viremia, platelet implantation time, and serostatus of CMV-IgG were more easily to develop CMVR than controls (p < 0.001, p = 0.003, p < 0.001, p = 0.032, p = 0.038, respectively). Multivariate logistic regression analysis showed that stem cells source (OR 7.823, 95% CI 1.759-34.800), HLA-match types (OR 7.452, 95% CI 1.099-50.542), and post-transplant EBV infection (OR 7.510, 95% CI 1.903-29.640) were positively associated with the onset of CMVR.

CONCLUSION

Stem cells derived from bone marrow and peripheral blood, HLA-match types, and post-transplant EBV viremia are important risk predictors of CMVR in allo-HSCT patients. These results suggest that clinicians should pay more attention to these indicators when formulating preventive measures pre- and post-transplant.

The Potential Association of Delayed T Lymphocyte Reconstitution Within Six Months Post-Transplantation With the Risk of Cytomegalovirus Retinitis in Severe Aplastic Anemia Recipients

Background

Delayed immune reconstitution after allogeneic hematopoietic stem cell transplantation (HSCT) is significantly associated with cytomegalovirus (CMV) infection. The aim of this study was to observe the recovery trend of peripheral lymphocyte subsets and immunoglobulins in HSCT recipients who developed CMV retinitis (CMVR).

Methods

We identified 37 CMVR cases and 303 non-CMVR controls in this case-control study from a database of 404 consecutive severe aplastic anemia patients who received allogeneic HSCT at a single center between 2015 and 2020. We analyzed the transplant outcomes and immune reconstitution principles with a focus on lymphocyte CD series and immunoglobulin series within the first year post-HSCT.

Results

Thirty-seven patients (55 eyes) were diagnosed with CMVR, with a mean onset time of 155 days post-HSCT. Among the 37 patients, one never had CMV detected in his blood but had a high CMV load in his intraocular fluid at the time of CMVR diagnosis. In the controls, 195 had CMV viremia and 108 did not. Compared with controls, CMVR cases had a longer duration of CMV viremia and a higher peak number of CMV load. T lymphocyte subsets including CD3, CD4 and CD8 were significantly lower in CMVR cases within six months after HSCT (all p < 0.05). Immunoglobulins also showed a slower recovery trend in CMVR cases. The recovery of B lymphocytes and natural killer cells exhibited no significant differences between the two groups.

Conclusions

It is not enough to develop fundus screening strategies by merely relying on the CMV serostatus of recipients. Dynamic and continuous monitoring of T lymphocyte subsets, especially within six months post-HSCT, as well as serum immunoglobulin levels, can provide assistance with screening program of CMVR in HSCT recipients with severe aplastic anemia.