Risk Factors for early CMV reactivation and Impact of early CMV reactivation on Clinical Outcomes after T Cell-replete Haploidentical Transplantation with Post-transplant Cyclophosphamide

Background: Cytomegalovirus (CMV) infection is a major cause of morbidity and mortality after hematopoietic stem cell transplantation (HSCT). It causes end-organ disease, multi-organ dysfunction syndrome, graft failure, increased susceptibility to infections and GVHD. According to the published western data greatest risk of CMV infection is the seropositivity of the recipient, however, in a high endemic population where seropositivity is up to 100%, risk factors for CMV reactivation are different and are analyzed in this study. Methods: It is a prospective descriptive study performed at Armed Forces Bone Marrow Transplant Center, Rawalpindi, Pakistan from January 2017 to March 2020. Consecutive patients who underwent allogeneic HSCT during this period were enrolled. All patients were prospectively monitored for CMV reactivation by weekly or two weekly CMV DNA quantitative PCR, from engraftment till day 100 post-transplant. CMV infection was diagnosed on detection of more than 200 copies/ml on PCR. Threshold for starting preemptive antiviral therapy was kept at 2000 copies/ml. Patients with past history of CMV infection, those who expired before day 14 post-transplant or those with less than 70% of required CMV tests were not included in the study. Factors associated with CMV reactivation, outcome of antiviral therapy and effect of CMV on post-transplant survival were studied. Results: Out of 319 transplants during this period, 230 patients fulfilled the inclusion criteria. Of these, 197 were HLA matched sibling, 18 were matched family donor and 15 were haploidentical transplants. There were 163 males and 67 females. Median age at transplant was 9.5 years (0.5-53). Eighty-three transplants were done in thalassemia, 55 in aplastic anemia, 14 in Fanconi anemia, 27 in acute leukemias, 8 in CML, 9 in MDS, 12 in HLH and 22 in other hematological disorders. All the patients and donor were CMV IgG seropositive when tested before transplantation. CMV reactivation was seen in 152 out of 230 patients (66.1%). Of 152, 95 patients had CMV viral load more than 2000 copies/ml and required antiviral treatment. Median time to reactivation since transplant was 35 days (13-90). In multivariate analysis using binary regression, risk factors for high viral load CMV reactivation included steroid administration (p=0.009), recipient age less than 10 years (p=0.003) and haploidentical transplant (p=0.048). No statistically significant association was found with the use of ATG, GVHD, underlying disease, ABO blood group or gender mismatch. Survival analysis using cox regression showed significant impact of high viral load CMV reactivation on post-transplant survival. Event-free survival (EFS) with and without CMV reactivation was 70.5 % and 89.7% respectively (p=0.004) and overall survival (OS) was 80.0 % and 97.4 % with and without CMV reactivation respectively (p=0.002). Valganciclovir was given in 89 patients and 6patients were treated with ganciclovir. Mean time to clear viremia was 19.8±9 days. Myelosuppression was seen in 41% of patients treated with valganciclovir. Renal impairment was seen in 25% of patients treated with valganciclovir. One patient had resistant disease. One patient had CMV pneumonia and she recovered. One patient died of suspected CMV pneumonia Conclusion: CMV reactivation was seen in 66.1% of the transplant recipients, this is higher compared to the western world due to high CMV seropositivity is this region. Steroids administration in post-transplant period significantly increase the risk of CMV reactivation. Preemptive therapy with valganciclovir effectively treats CMV reactivation. Viral threshold for treatment should be decided considering the regional endemicity. CMV adversely effects the transplant outcome in terms of EFS and OS. Disclosures No relevant conflicts of interest to declare.

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Nonmyeloablative Conditioning Regimen before T Cell Replete Haploidentical Transplantation with Post-Transplant Cyclophosphamide for Advanced Hodgkin and Non-Hodgkin Lymphomas

Biology of Blood and Marrow Transplantation ◽

10.1016/j.bbmt.2020.08.014 ◽

2020 ◽

Vol 26 (12) ◽

pp. 2299-2305

Author(s):

Catalina Montes de Oca ◽

Luca Castagna ◽

Chiara De Philippis ◽

Stefania Bramanti ◽

Jean Marc Schiano ◽

...

Keyword(s):

T Cell ◽

Conditioning Regimen ◽

Post Transplant ◽

Haploidentical Transplantation

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84 Predictive risk factors of post-transplant high-grade CMV reactivation in CMV-seropositive patients in the modern immunosuppressive era

European Urology Supplements ◽

10.1016/s1569-9056(15)60086-0 ◽

2015 ◽

Vol 14 (2) ◽

pp. e84

Author(s):

R. Yamamoto ◽

M. Saito ◽

S. Satoh ◽

H. Tsuruta ◽

S. Akihama ◽

...

Keyword(s):

Risk Factors ◽

High Grade ◽

Post Transplant ◽

Predictive Risk ◽

Cmv Reactivation

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Lineage–Specific Chimerism and Incidence of Graft-Failure Following T-Cell Replete Haploidentical Transplantation Using Post-Transplant Cyclophosphamide in Eighty-Nine Consecutive Patients From a Single-Center.

Blood ◽

10.1182/blood.v120.21.3030.3030 ◽

2012 ◽

Vol 120 (21) ◽

pp. 3030-3030

Author(s):

Amaani Hussain ◽

Connie A. Sizemore ◽

Xu Zhang ◽

Melissa Sanacore ◽

Stacey Brown ◽

...

Keyword(s):

T Cells ◽

T Cell ◽

Graft Failure ◽

Myeloid Cells ◽

Time Points ◽

Post Transplant ◽

Haploidentical Transplantation ◽

Cell Engraftment ◽

Preparative Regimen ◽

Spontaneous Improvement

Abstract Abstract 3030 T-cell replete HLA-haploidentical transplantation using post-transplant cyclophosphamide for prevention of GVHD and graft rejection (Haplo-PTCy) has recently emerged as a valid form of alternative-donor transplantation for patients who lack traditional matched-siblings (MSD) or matched-unrelated donors (MUD). We have demonstrated that patients undergoing Haplo-PTCy can have equivalent rates overall and disease-free survival and equivalent or lower cumulative incidences of GVHD and non-relapse mortality to patients transplanted contemporaneously from MSD and MUD at the same center (Bashey et al ASH 2011 abstract #833). In this study we assessed lineage-specific chimerism, together with incidence and outcome of graft-failure in 89 consecutive first Haplo-PTCy performed for hematologic malignancy in our center between Oct 2005 and Jun 2012. Patient characteristics: M 48, F 41; median age 48 (20–74); Diagnosis AML 28, ALL 16, CLL 11, NHL 9, HL 8, CML 8, MDS 7, MPS 2; median number of matched HLA loci were 5/10 (range 5/10 to 8/10); Median CD34+ and CD3+ cell dose infused were 4.01 × 106/kg (0.84–6.27) and 5.35 × 107/kg (1.4–53.82) respectively. Fifty-eight patients received a marrow graft and 31 received G-CSF mobilized PBSC. The preparative regimen was RIC/NST in 59 (fludarabine 30 mg/m2/d d -6 to -2, TBI 200cGy d-1, cyclophosphamide 14.5 mg/kg/d d-6 & -5, and 50 mg/kg/d d+3 & +4) and myeloablative in 30 (regimen A- fludarabine 30 mg/m2/d d -6 to -2, busulfan 110–130 mg/m2/d d-7 to -4, cyclophosphamide 14.5 mg/kg/d d-3 & -2, and 50 mg/kg/g d+3 & +4 [20 patients] and regimen B- fludarabine 30 mg/m2/d d -7 to -5, TBI 1200 cGy given in 8 fractions between days-4 to -1 and cyclophosphamide 50 mg/kg/d d +3 & +4 [10 patients]). The presence of pre-transplant anti-donor HLA antibodies were assessed using a solid phase assay (Panel Reactive Antibody, PRA, Clinimmune, CO) and by anti-donor cross-matching by flow cytometry (Clinimmune). All donors were selected to provide a negative cross-match using recipient serum and donor T-cells prior to transplant. Engraftment was determined using standard CIBMTR criteria. Lineage-specific chimerism was determined using PCR for short tandem repeats on peripheral blood mononuclear cells separated by CD3 and CD33 expression using immunomagnetic beads on d 30,60,90 and 180 following transplant. Median time to ANC > 500/mm3 was 16d (12–27d) and platelets > 20,000/mm3 was 26d (0–26d). Median T-cell (CD3) and myeloid (CD33) donor chimerisms were 100%, at all time-points assessed from d30–180 (Fig 1). All 30 patients who received a myeloablative Haplo-PTCy had full engraftment of T-cells and myeloid cells starting d +30. However six of 59 patients undergoing RIC/NST Haplo-PTCy had primary failure of T-cell engraftment -median CD3 chimerism (range) for these patients on d 30 and 60 were 0% (0–6%) and 0% (0–14%). Median CD33+ cell chimerism for the same patients on d 30 and 60 respectively were 86% (0–100%) and 45% (0–100%). Four of these patients underwent a second Haplo-PTCy, a median of 105d (range 8–123d) following the first transplant using a different haploidentical donor and the same preparative regimen. In each case the second Haplo-PTCy was successful (CD3+ donor chimerism 100% by d 30–60 in all cases). One patient who was too unwell for second Haplo-PTCy had spontaneous improvement in CD3 chimerism (6–14% d 30–90 improving to 100% d 180) and one patient died of progressive malignancy before a second Haplo-PTCy could be performed. These data demonstrate that full donor chimerism of T-cells and myeloid cells is usual following Haplo-PTCy from the earliest time-points assessed. Engraftment failure was not seen in any patient using the myeloablative regimens described above. Approximately 10% of patients conditioned with the RIC/NST regimen failed to undergo initial T-cell engraftment. However, re-transplantation was successful in all cases when attempted. Late spontaneous improvement of CD3 chimerism is also possible in patients with low level mixed chimerism early post-transplant. Fig 1. Fig 1. Disclosures: No relevant conflicts of interest to declare.

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The Frequency of Cytomegalovirus (CMV)-Specific CD8+ T Cells Distinguishes CMV Clinical Outcomes Following Hematopoietic Allogeneic Stem Cell Transplant: A Prospective Multicentre Cohort Study

Blood ◽

10.1182/blood.v126.23.4312.4312 ◽

2015 ◽

Vol 126 (23) ◽

pp. 4312-4312

Author(s):

Michelle K Yong ◽

Monica Slavin ◽

David S. Ritchie ◽

Andrew Spencer ◽

Paul U Cameron ◽

...

Keyword(s):

T Cell ◽

Clinical Outcomes ◽

T Cell Immunity ◽

Cell Transplant ◽

Viral Control ◽

Specific Immunity ◽

Cell Immunity ◽

Ifn Γ ◽

Cmv Disease ◽

Cmv Reactivation

Abstract Introduction: A simple test to identify recovery of CMV-specific T cell immunity in the post hematopoietic stem cell transplant (HSCT) period could assist clinicians in managing CMV related complications. The current assays of cell mediated immunity require specialised personnel and equipment, take a long time to perform and are often not available in a routine diagnostic laboratory. We therefore assessed CMV-specific CD8+ T cell immunity using a rapid high throughput Quantiferon-CMV assay to characterise the kinetics of CMV-specific immunity following HSCT. Methods: An observational multi-centre prospective study of allogeneic HSCT recipients who were at risk of CMV disease was conducted. Study bloods were taken pre-transplant and at 3, 6, 9 and 12 months post-HSCT. CMV-specific immunity was assessed using the Quantiferon-CMV assay which quantifies interferon gamma (IFN-γ) production by ELISA following stimulation with 22 CMV peptides derived from pp65, IE1, IE2, pp50, pp28 and gB, as well as a traditional ELISPOT assay using CMV overlapping peptide pools covering pp65 and IE1. The Quantiferon-CMV assay provides qualitative (reactive, non-reactive, indeterminate) and quantitative results expressed as IFN-γ levels (IU/ml). All participants had CMV surveillance with weekly CMV-PCR until day 100 or beyond in presence of graft versus host disease (GVHD). Participants were either managed with universal routine ganciclovir prophylaxis or CMV monitoring with pre-emptive treatment depending on the treating institution. CMV clinical outcomes were classified as (1) CMV disease with clear tissue involvement, (2) treated CMV reactivation (CMV DNA ³600cp/ml plus antivirals) and (3) spontaneous viral control defined as the resolution of any level of CMV DNA without CMV directed antivirals. Results: The median age of participants (n=94) was 51 years (IQR 40-56) and the most common indication for transplantation was AML (35%). Sixty-three percent of transplants received myeloablative conditioning, 54% had unrelated donors and 9% were umbilical cord transplants. Seventy-three percent of patients underwent pre-emptive CMV monitoring whilst 27% were on universal prophylaxis. CMV clinical outcomes included CMV disease (n=8), treated CMV reactivation (n=26), spontaneous viral control (n=25) and no detectable CMV DNA (n=31). A further 4 patients had low level viremia (CMV DNA<600copies/ml) treated with antiviral agents. CMV reactivation and CMV disease occurred at a median of 48 and 65 days respectively post HCT. Significant risk factors for CMV disease were donor/recipient CMV serostatus R+/D- (p=0.004), umbilical cord transplant (p=0.003) and acute GVHD (p=0.03). At baseline, there was no difference in the level of IFN-γ producing CMV specific T cells (Quantiferon) between patients who subsequently had CMV disease, CMV reactivation or spontaneous viral control (p=0.24). At 3 months post HSCT patients with CMV disease had significantly lower CMV IFN-γ responses compared to those with CMV reactivation or spontaneous viral control (median IFN-γ 0.04 vs 0.23 vs 1.86 IU/ml respectively, K-Wallis test p=0.001). An indeterminate Quantiferon-CMV result at 3 months was associated with CMV disease (p=0.001) whereas a reactive test was associated with spontaneous viral control (p=0.002). There were no significant differences in CMV IFN-γ levels measured by the Quantiferon-CMV assay results between the clinical groups at 6, 9 or 12 months post HSCT. A significant delay was observed in the time to development of CMV-specific immunity (defined as IFN-γ ³0.1IU/ml) in patients with CMV disease compared to CMV reactivation and spontaneous control (median time 240 vs 110 vs 97 days Mantel-Cox logrank test p=0.02). Twelve month survival was strongly associated with the Quantiferon-CMV result measured 3 months post HSCT being non-reactive, reactive or indeterminate (100% vs 90% vs 61.9% respectively Mantel-Cox Logrank test p=0.002, Graph 1). Conclusion: At 3 months post HSCT, the results of the Quantiferon-CMV assay which measures CMV-specific CD8+ T cell immunity can identify clinically relevant CMV related outcomes including 12 month survival. The Quantiferon-CMV assay may compliment current CMV prophylactic strategies and assist clinicians to identify patients at high risk of CMV related complications and poor survival. Figure 1. Twelve month survival curve by 3 month Quantiferon-CMV assay result Figure 1. Twelve month survival curve by 3 month Quantiferon-CMV assay result Disclosures No relevant conflicts of interest to declare.

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Recovery of CMV-Specific T Cells Following Alternative Donor Allogeneic Transplant with Post-Transplant Cyclophosphamide

Blood ◽

10.1182/blood.v126.23.5462.5462 ◽

2015 ◽

Vol 126 (23) ◽

pp. 5462-5462

Author(s):

Ayman Saad ◽

Samantha B Langford ◽

Shin Mineishi ◽

Lawrence S. Lamb

Keyword(s):

T Cells ◽

T Cell ◽

Cd8 T Cells ◽

Cell Response ◽

Cd8 T Cell ◽

T Cell Response ◽

Cell Recovery ◽

Post Transplant ◽

Increased Risk ◽

Cmv Reactivation

Abstract Background: Post-transplant cyclophosphamide (PTCy) is increasingly used for GVHD prophylaxis after allogeneic hematopoietic stem cell transplantation (HCT) using alternative donors. However, immune reconstitution can be delayed posing an increased risk for CMV reactivation. We evaluated the outcomes of patients who received HCT-apheresis products comparing the impact of PTCy on lymphocyte recovery, CMV reactivation and CMV-specific CD8+ T cell recovery following haplo-identical (HAPLO), matched unrelated donor (MUD), and mismatched unrelated donor (mMUD) grafts vs. with conventional matched related donor (MRD) graft recipients. Methods: We examined 26 patients (median age, 49 years; range, 20-72 years) with advanced hematologic malignancies; n=5 (HAPLO); 6 (MRD); 15 (MUD). All patients received myeloablative conditioning regimens that was either busulfan- or total body irradiation (TBI)-based. PTCy (50 mg/kg/day) was administered on days +3 and +4 following HAPLO and on day +3 following MUD/mMUD transplant. Peripheral blood lymphocyte reconstitution and frequency of circulating CMV-directed CD8+ T cells was assessed (day ± 10 days) on post-transplant days +30, +60, and +90. Circulating anti-CMV T cell frequency was assessed using a phycoerythrin-tagged MHC dextramer against HLA-specific CMV pp65, IE-1, or pp50 peptides (Immudex; Copenhagen, DK) in combination with Tru-Count¨ tubes and fluorescent-labeled monoclonal antibodies against CD3, CD8, CD4, CD16/56, and CD19 (BD Biosciences; San Jose, CA). Anti-CMV CD8+ T cell immunity was defined as a CMV-dextramer (CMV/DEX) positive count of ≥7cells/ml. CMV reactivation was defined as a serologic titer of >500IU/mL. All patients with CMV reactivation received ganciclovir therapy until CMV titer became negative. Results: Day +30 total T cell recovery was significantly faster in MRD than CY-treated recipients (p=0.015) due principally to more robust CD8+ T cell recovery. CD4 T cell recovery remained below normal range in all groups through day +100. NK cells recovered to normal numbers at day +28 in all groups. Neither PTCy nor donor source significantly impacted the percentage of patients that recovered anti-CMV CD8+ T cells at each time interval (p = 0.8232). Excluding donors (D) and recipients (R) that were both negative, CMV/DEX+ T cells recovery was >7/mL in 4/5 MRD, 7/14 MUD, and 3/5 HAPLO by day +100. Among MRD recipients either D+ or R+ (n=5), 2 patients showed CMV reactivation within 40 days of transplant that was associated with <7 CMV/DEX+ T cells on day +30. Subsequent high (>90/mL) CMV/DEX T cell response in one patient shortened the duration of viremia to 10 days (vs. 16 days with poor responder) and 3 patients showed no CMV reactivation and a high CMV/DEX+ T cell response by day +60. For MUD CMV D+ and/or R+ recipients (n=14), 3 showed CMV reactivation within 50 days of transplant. All 3 patients had suboptimal CMV/DEX T cell response on day +30. Robust CMV/DEX+ T cell response on day +60 predicted shorter duration of viremia (20 days vs. average of 32 days). For HAPLO CMV D+ and/or R+ (n=5) recipients, 4 experienced CMV reactivation within 50 days of transplant. All patients had a <7 CMV/DEX+ T cells/mL +30. Robust CMV/DEX+ T cell response by day +60 was associated with shorter duration of viremia (range 7-21 days), while one patient with <7/mL CMV/DEX+ T cells had continued CMV viremia for 36 days. Conclusion: In this preliminary analysis, neither PTCy nor donor source significantly impacted the percentage of patients that recovered anti-CMV CD8+ T cells at each time interval. A weak CMV/DEX+ response (<7 cells/mL) on day +30 was consistent with increased risk of CMV reactivation (viremia) in all groups. A CMV/DEX+ T cell count ≥7 cells/mL was not immediately protective against CMV reactivation, but higher counts were associated with a shortened duration of viremia while on antiviral therapy. Conversely, subnormal counts were associated with a longer duration of viremia. This interim analysis suggests that CMV/DEX+ T cell enumeration is a useful biologic correlate for determining clinical response to antiviral therapy, and that donor-derived CMV specific T cell immunity is not further compromised with following PTCy in alternative donor HCT. Disclosures No relevant conflicts of interest to declare.

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Letermovir Administration to Prevent Cytomegalovirus Reactivation Is the Potential Risk of Chronic Graft-Versus-Host Disease in Patients Who Received Haploidentical Stem-Cell Transplantation With Post-Transplant Cyclophosphamide

Frontiers in Oncology ◽

10.3389/fonc.2021.666774 ◽

2021 ◽

Vol 11 ◽

Author(s):

Toshiki Terao ◽

Ken-ichi Matsuoka ◽

Kentaro Narita ◽

Takafumi Tsushima ◽

Satoshi Yuyama ◽

...

Keyword(s):

T Cells ◽

Stem Cell ◽

T Cell ◽

Stem Cell Transplantation ◽

Cell Transplantation ◽

Cell Recovery ◽

Activated T Cells ◽

Post Transplant ◽

Hla Dr ◽

Cmv Reactivation

The prevention of chronic graft-versus-host disease (cGVHD) is important for recipients of hematopoietic stem-cell transplantation (HSCT). As one of the etiologies, the relationship between early T-cell recovery and subsequent cGVHD development has been the focus of attention. Recently, letermovir (LTV) was approved for preventing cytomegalovirus (CMV) reactivation in the early transplantation phase. Although CMV affects the immune reconstitution after HSCT, the impacts of LTV to prevent CMV reactivation on early T-cell recovery and cGVHD have not been fully investigated. We aimed to identify early T-cell recovery under LTV at day 30 in 15 and 33 recipients from matched related donors (MRDs) and haploidentical donors with post-transplant cyclophosphamide (PTCy-haplo), respectively. Early increases in the levels of total lymphocytes and HLA-DR+ activated T-cells at day 30 were observed under CMV prophylaxis by LTV only in PTCy-haplo recipients and not in MRD recipients. Moreover, PTCy-haplo recipients with LTV showed a significantly higher incidence of cGVHD, but not acute GVHD. Our observations suggest that an early increase in the levels of HLA-DR+ activated T-cells may be implicated in the development of cGVHD in patients treated with PTCy who received LTV. Further studies are warranted to validate our results and elucidate the detailed mechanisms of our new insights.

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