Daniela Caldera

Human cytomegalovirus-specific CD4+ and CD8+ T-cell reconstitution in adult allogeneic hematopoietic stem cell transplant recipients and immune control of viral infection

Human cytomegalovirus infection is the most frequent viral complication in patients undergoing hematopoietic stem cell transplantation. Pre-transplant human cytomegalovirus serostatus of the recipient is the main trigger for specific T-cellreconstitution. Background Human cytomegalovirus infection is the most frequent viral complication in patients undergoing hematopoietic stem cell transplantation. We investigated the development of human cytomegalovirus-specific T cells in adult recipients of hematopoietic stem cell transplants. Design and Methods From May 2003 through October 2006 a total of 45 patients were monitored for human cytomegalovirus-specific T-cell reconstitution. Human cytomegalovirus-infected autologous dendritic cells were used as a stimulus to detect interferon-γ-producing human cytomegalovirus-specific CD8+ and CD4+ T cells during the first year after transplantation. Interleukin-2 production by specific T cells was also determined. Figure 1. Probability of HCMV infection development and HCMV-specific CD4+ and CD8+ T-cell immunity reconstitution. A: cumulative incidence curves of HCMV infection according to donor (D) and recipient (R) HCMV-serostatus. B: cumulative incidence curves of HCMV infection and HCMV-specific CD8+ and CD4+ T-cell reconstitution (i.e. corresponding to a specific T-cell number greater than 0.4 cells/μL blood). C: cumulative incidence curves of HCMV-specific CD8+ T-cell reconstitution according to D/R HCMV-serostatus. D: cumulative incidence curves of HCMV-specific CD4+ T-cell reconstitution according to D/R HCMV-serostatus. Results Human cytomegalovirus infection was detected in the blood of 39/45 patients at a median of 29 days after transplantation. Human cytomegalovirus-specific T-cell reconstitution followed reactivation of latent human cytomegalovirus infection at a median time of about 2 months after transplantation. Only donor human cytomegalovirus-seronegativity and bone marrow as a stem cell source were found to delay specific T-cell reconstitution significantly. Levels of three CD8+ and one CD4+ human cytomegalovirus-specific T-cells/μL blood had a positive predictive value of around 80% for identifying patients able to control human cytomegalovirus infection spontaneously. Five patients who received high doses of steroids for treatment of graft-versus-host disease developed human cytomegalovirus infection requiring pre-emptive treatment despite high levels of interferon-γ-producing T cells in response to human cytomegalovirus. Specific interleukin-2 production was not detected in patients with human cytomegalovirus infection requiring treatment, while 90% of patients who spontaneously controlled human cytomegalovirus infection had T cells that produced interleukin-2 and interferon-γ. Conclusions Pre-transplant human cytomegalovirus infection of the recipient is a major factor driving human cytomegalovirus-specific immune reconstitution. Control of human cytomegalovirus infection likely requires the presence of both interferon-γ and interleukin-2 producing T cells. Corticosteroid treatment may favor active viral replication even in patients with specific T cells.

Validation of a DNAemia cutoff for preemptive therapy of cytomegalovirus infection in adult hematopoietic stem cell transplant recipients

A randomized trial comparing a DNAemia cutoff of 10 000 copies per ml whole blood and first pp65 antigenemia positivity for initiation of preemptive therapy of human cytomegalovirus (HCMV) infection in adult hematopoietic stem cell transplant recipients was completed. DNAemia was chosen for cutoff definition since it is more automatable and standardizable than antigenemia, and more closely reflects the actual viral replication. The primary end point of the study was to compare the number of patients treated in the two arms. A total of 83 patients (42 in the DNAemia, and 41 in the antigenemia arm) were enrolled in the study. The incidence of HCMV infection, as detected by the relevant randomization assay (76% in the DNAemia versus 85% in the antigenemia arm), was comparable in the two arms, whereas the number of patients treated was significantly lower in the DNAemia arm (63 versus 80%, P=0.02). A single patient in the DNAemia arm suffered from biopsy-proven HCMV gastric disease diagnosed in the absence of detectable virus in blood. The incidence of graft-versus-host disease, and transplantation-related mortality did not differ between the two arms. In conclusion, our study shows that the use of a cutoff significantly reduces the number of patients requiring antiviral treatment, thus sparing unnecessary drug administration.

Nephrotic syndrome after allogeneic hematopoietic stem cell transplantation as a late complication of chronic graft-versus-host disease.

Background. This study aims to determine the incidence and outcome of nephrotic syndrome in patients who underwent allogeneic stem cell transplantation in a single center. Methods. Records of 279 adult patients with hematological diseases who underwent allogeneic hematopoietic stem cell transplantation were analyzed to evaluate the incidence and outcome of nephrotic syndrome. The diagnosis of chronic graft-versus-host disease was based on clinical evidence with histological confirmation whenever possible. Results. Of the 279 patients, 105 with a minimum follow-up of 100 days developed chronic graft-versus-host disease: six of these had nephrotic syndrome. The cumulative incidence of nephrotic syndrome was 8% at day +1681. Patients grafted with peripheral blood stem cells had a higher probability of developing nephrotic syndrome than did those grafted with bone marrow: 24% and 3%, respectively. The pathological diagnosis was membranous glomerulonephritis in four patients, and minimal change disease in one; the diagnosis could not be histologically confirmed in the sixth patient. All patients had extensive chronic graft-versus-host disease and were receiving treatment with cyclosporine A and steroids (four patients). Response to immunosuppressive therapy with cyclosporine A and steroids was achieved in all patients at a median time of 12 weeks after transplantation. Conclusion. Patients with chronic graft-versus-host disease may be considered to be at risk of nephrotic syndrome: careful monitoring of renal function is advisable, particularly in patients receiving allogeneic peripheral stem cell grafts.

Long-term control of extensive refractory chronic graft versus host disease in a multiple myeloma relapsing after allogeneic transplant. A case report

Multiple myeloma (MM) is an incurable hematological malignancy. Allogeneic stem cell transplantation (ASCT) represents a possible curative option for a subset of young and fit patients having a HLA-identical sibling. The long-term impact of ASCT is still hampered by significant early and long-term morbidity and mortality mainly due to graft versus host disease (GvHD). Some degree of chronic GVHD (cGvHD) was reported in about half of patients after allotransplant independently by their hematological disease. Chronic GvHD management still relies on corticosteroid administration, with 10% of patients who need continuous immunosuppression for an indefinite period [1]. Notably 50–60% of patients developing cGvHD requires secondary immunosuppressive agent other than steroids in the light of worsening manifestation of cGvHD as well as for emergent steroid related toxicity [2,3]. Pre-clinical data [4–6] had prompted evidences of the crucial role of Bortezomib mediated NF-kB inhibition for immune regulation, opening the way for its successful use in steroid refractory cGvHD developing in myeloma patients relapsing after allotransplant [7–10]. In these reports Bortezomib was administered twice-weekly at conventional doses for a median of 6–8 cycles then stopped. There are limited data regarding the feasibility of long-term administration of low-dose Bortezomib with the aim of obtaining persistent inhibition of cGVHD while preserving anti-myeloma effect. A young woman, with a previous history in 2001 of solitary plasmacytoma at lumbar tract treated with radiotherapy, progressed to light chain symptomatic myeloma in 2005, when she was 31 years old, with appearance of diffuse bone lesions. She received four Bortezomib plus dexamethasone (BD) cycles as induction followed by a tandem auto-allo transplant from an HLA identical sibling. Conditioning regimen consisted of myeloablative conventional doses of busulfan plus melphalan followed by standard acute GvHD (aGvHD) prophylaxis with calcineurin inhibitors plus methotrexate, obtaining a full donor chimerism and a very good partial remission (VGPR) according to IMWG criteria [11]. No significant sign of aGvHD was documented except for mild anorexia and nausea completely resolved at 30 days after transplant. Three months after transplant, she was diagnosed with chronic severe GvHD according to NHI global score [12]. Affected sites included skin (score1⁄4 3), mouth (score1⁄4 2) and fasciae (score1⁄4 3) with the consequent need of primary systemic treatment with prednisone 1mg/kg obtaining only slight initial improvement of cGVHD. In September 2007, seven months after transplant, there was a progressive worsening of GvHD manifestations with extension of skin and fasciae involvement (extensive skin depigmentation and papulo-squamous lesions involving more than 70% of body surface area, progressive joints contractures significantly limiting ADL); secondary systemic therapy with mycophenolate was started and maintained until January 2010 when there was a further significant spread of skin involvement (diffuse keratosis with extensive hypo-depigmentation and dermal sclerosis). Extracorporeal photopheresis (ECP) was started in addition to the ongoing mycophenolate, obtaining a stabilization of sclerosis and slight improvement of keratosis. Partial remission with full donor chimerism was maintained until September 2010, when isolated new lytic bone lesion occurred (dorsal tract vertebral collapse, treated with kyphoplasty followed by local radiation). Soon after (December 2010), cGvHD skin and joint involvement worsened, with a consequent need for additional immunosuppression with four weekly doses of Rituximab followed by continuous low dose Thalidomide; IMiDs-based therapy was effective either for management of cGvHD symptoms as well as for myeloma control, with mild toxicity (grade 2 peripheral neuropathy). Overt myeloma progression, with diffuse bone involvement and serum and urine monoclonal component reappearance, was documented in December 2013, eight year after allotransplant. In the same there was a worsening of cGvHD characterized by severe joint stiffness (score 3) and cutaneous deep sclerosis involving