Monit itorin ing of of CMV MV infect ctions in tran ansplan - - PowerPoint PPT Presentation

Monit itorin ing of

• f CMV

MV infect ctions in tran ansplan lant recipients base sed on C CMV MV specif ific ic cell ll-mediat iated immunity (CM CMI)

Dr. Veronica D Di Cristanziano Institute of Virology, University of Cologne

Cytomegalovirus (CMV)

• CMV is a ubiquitous β-herpes virus, which infects about 50-90% of the

adult population worldwide

• CMV is never cleared after primary infection, but persists for the

lifetime of the host, establishing a latent infection characterized by limited viral gene expression

• Endothelial cells and cells of myeloid lineage (CD34+ hematopoietic

progenitors, CD33+ granulocyte-macrophage progenitors and monocyte-derived macrophages) are considered critical sites of CMV persistence and latency

• Human immune system cannot eliminate CMV but it is capable of

controlling CMV replication

• CMV is generally asymptomatic within the normal individual but can

cause severe disease in immunocompromised patients (pneumonia, hepatitis, colitis, retinitis, encephalitis)

• Transplant recipients (allo-HSCT, SOT)

Pre-transplant CMV assessment

• Seropositivity (positive CMV IgG) is used as biomarker for latent CMV infection
• CMV-specific Ab of donor and recipient is the key diagnostic assay pre-Tx to stratify

the risk of CMV replication and disease post-TX

Post-transplant CMV assessment

• Viral load monitoring (quantitative real-time PCR)
• Frequency, duration, treatment threshold as well as material (plasma, WB) and unite of

measure (cop/ml, IU/ml, cop/µg DNA) vary widely between transplant centers

Strategies for prevention of CMV infection/disease in transplant recipients

Preemptive therapy:

• It consists of initiating anti-CMV drugs once CMV is detected at a certain

threshold in whole blood or plasma regardless of clinical symptoms

• The most common practice for prevention of CMV infection after allo-HSCT in

most cancer centers

• A specific threshold for therapy initiation is not well defined
• Considering the toxic effects of the available antiviral agents, this strategy could

be detrimental for patients at low risk for CMV disease Prophylactic approach:

• Administration of anti-CMV agents for 3-6 months post-transplantation
• Largely used in case of SOT but unpopular in case of allo-HSCT
• Letermovir (LMV) was approved for CMV prophylaxis after allo-HSCT (no

evidence of myelotoxicity or nephrotoxicity

• Risk of CMV reactivation at the end of prophylaxis (late-onset CMV infection)

CMV after allo-HSCT

• CMV is the most common opportunistic viral infection in allo-HSCT

recipients

• CMV seropositive patients are considered to be at high risk for CMV

reactivation

• D−/R+ > D+/R+ > D+/R− > D−/R−
• Around 5% of CMV seropositive allo-HSCT recipients develops CMV

end-organ disease

• CMV infections are associated with graft failure, graft-versus-host

disease (GVHD), and secondary bacterial and fungal infections

CMV after kidney transplantation

• Highest risk of CMV infection in case of D+/R-
• Late-onset disease (CMV viraemia occurring following

cessation of prophylaxis)

• Allograft rejection and increased mortality

Strategies for prevention of CMV infection/disease in transplant recipients

Preemptive therapy:

• It consists of initiating anti-CMV drugs once CMV is detected at a certain threshold in

whole blood or plasma regardless of clinical symptoms

• The most common practice for prevention of CMV infection after allo-HSCT in most

cancer centers

• A specific threshold for therapy initiation is not well defined
• Considering the toxic effects of the available antiviral agents, this strategy could be

detrimental for patients at low risk for CMV disease

• How can we stratify the risk to develop CMV disease?

Prophylactic approach:

• Administration of anti-CMV agents for 3-6 months post-transplantation
• Largely used in case of SOT but unpopular in case of allo-HSCT
• Letermovir (LMV) was approved for CMV prophylaxis after allo-HSCT (no evidence of

myelotoxicity or nephrotoxicity

• Risk of CMV reactivation at the end of prophylaxis (late-onset CMV infection)
• How can we stratify the risk to develop CMV disease?

Consensus-Guideline 2018

“Immune monitoring of CMV-specific T-cell responses can predict individuals at increased risk

• f CMV disease posttransplant and may be useful

in guiding prophylaxis and preemptive therapies.“

The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation, Transplantation 2018

CMV cellular mediated immunity (CMV-CMI)

• CMV-CMI is considered the primary defense mechanism to

control CMV replication

• Both CD4+ and CD8+ T cells are involved in the defense

against CMV infection with production of IFN-ɣ

• Measurement of CMV specific T cell activity may reflect

patients´ability to control CMV and predict the risk for post- transplant viral replication

• Measurement of IFN-ɣ release might be an useful biomarker

for CMV infection

CMV enzyme-linked immunosorbent spot (ELISPOT) assay

• 1. Peripheral blood mononuclear cells (PBMCs) are isolated from

whole blood. The cells are washed, counted and normalized to create a standard cell suspension.

• 2. A standard number of cells are added into specially designed

plates and stimulated with CMV-specific antigens pp65 and IE-1. Cells responding to these antigens release the cytokine IFN-ɣ

• 3. IFN- ɣ antibodies are used to directly capture IFN-ɣ as it is

released by the cells. A secondary labelled antibody is added and binds to the captured IFN- ɣ

• 4. A detection reagent is added and reacts with the secondary

labelled antibody. This reaction produces spots, which are footprints of where the IFN-ɣ was released. Spots are then enumerated.

Many recent publications showed that the assessment of CMV-specific immunity (ELISPOT) is able to predict protection from CMV infection in transplant recipients

Ongoing studies

• VIRENO study: viro-immunological monitoring

based on anti-BKPyV antibodies detection, CMV IGRA, and TTV-DNA before and 3 weeks and 6 months after KTx

• Viro-immunological monitoring after cessation

LMV prophylaxis in allo-HSCT recipients (IGRAs, TTV-DNA)

T-cell response in a healthy CMV seropositive individual

IE1 pp65 CTRL+

CMV reactivation in D+/R+

Rituximab Immunadsorptionen

Patient 1

Rituximab Immunadsorptionen

CMV reactivation in D+/R+

Patient 1

CMV Elispot monitoring in an allo-HSCT D-/R+ recipient after cessation of LMV prophylaxis

IE1 44 74 108 pp65 395 979 1056 CTRL+ 493 1212 1237 +200 day +220 day +280 day

Patient 2

+200 +210 +240 +270 +330 1250 IE1 3 1 2 6 47 pp65 20 23 116 147 230 CRTL+ 244 348 877 736 1009 870

CMV Elispot monitoring in an allo-HSCT D-/R+ recipient after cessation of LMV prophylaxis

Patient 3

Thank you, dankeschön, grazie

Klinik für Viszeral- und Transplantationschirurgie Institut für Virologie Klinik für Nephrologie

• Prof. Dirk Stippel
• Dr. Roger Wahba
• Dr. Georg Dieplinger
• Dr. Rolf Kaiser
• Dr. Eva Heger
• Dr. Elena Knops
• Dr. Gertrud Steger
• Prof. Florian Klein
• Dr. Roman Müller
• Prof. Christine Kurschat
• Dr. Martin Kann
• Joanna Wessel

Uniklinik Düsseldorf

• Dr. Ortwin Adams
• Dr. Nadine Lübke
• Prof. Guido Kobbe

Don´t forget it !