Treatment of HIV and acute myeloid leukemia by allogeneic CCR5-d32 - - PowerPoint PPT Presentation

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Treatment of HIV and acute myeloid leukemia by allogeneic CCR5-d32 - - PowerPoint PPT Presentation

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Treatment of HIV and acute myeloid leukemia by allogeneic CCR5-d32 blood stem cell transplantation Elena Knops / Bjrn Jensen AREVIR, Cologne 2018 Chapter I .... .... one week before SCT AREVIR, Cologne 2018 Chapter II June 2013 total

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AREVIR, Cologne 2018

Treatment of HIV and acute myeloid leukemia by allogeneic CCR5-d32 blood stem cell transplantation

Elena Knops / Björn Jensen

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AREVIR, Cologne 2018

Chapter I

.... ....

  • ne week before

SCT

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AREVIR, Cologne 2018

Chapter II

....

total of 8 courses of 5-azacytidine + 4 donor lymphocyte infusions

June 2013

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AREVIR, Cologne 2018

Chapter III

....

+ CMV, HHV8, HSV

  • PBMCs
  • rectal + ileum
  • bone marrow
  • CSF

Tacrolimus + topical steroids

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AREVIR, Cologne 2018

Chapter IV

....

2016 2017

ABC/3TC/DTG <20 <20 505 318

<LOQ (10 Mio) <LOQ (10 Mio) 1/10 repl <LOQ (3,8 Mio) <LOQ (15 Mio) 1/20 repl

63 month after SCT

<LOD (884250) in rectal and ileum biopsy

Tacrolimus + topical steroids

2018

negative qVOA (CD4 cell count) <LOQ (2,8 Mio) qVOA in humanized mouse model (CD4 cell count) negative (23 Mio) lymph node biopsy

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AREVIR, Cologne 2018

# sequencing genotypic prediction phenotypic analysis in Tcells Clone gp120-V3 amino acid sequence reads FPR (%) Magi (R5/X4) MT2 (X4) D1 CTRPNNNTREGIHIGPGRAFFTTGEIIGNIREASC 4 95,78 R5 R5 D2 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIKEAYC 2 95,64 R5 R5 D3 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIGEAYC 2 95,64 R5 R5 D4 CTRPNNNTRKGIHIGPGRAFFTTGEIIGNIREASC 2062 77,33 R5 R5 D5 CTRPNNNTRKGITIGPGRAFFTTGEIIGDIRQAHC 4886 30,67 R5 R5 D6 CTRPNNNTRKGIHIGSRKAFFTTGGIIGDIRQAYC 2 10,61 R5/X4 X4 D7 CTRPHTNTRKRIHIGPGRAFFTTGEIIGDIRQAYC 7 1,74 R5/X4 X4 D8 CTKPNNNTRKRIHIGPGRAFFTTGEIIGNIRQASC 2 1,74 R5 R5 D9 CTRPNNNIRKRIHIGPGRAFFTTGEIIGNIREAYC 3 1,16 R5/X4 X4

HxB2V3Bal

control R5 51,8 R5 R5 HxB2 control X4 X4 X4

Monique Nijhuis, Utrecht, ICISTEM

CO-RECEPTOR TROPISM

(sample before transplantation, PBMC)

Chapter V

NGS: 0,14 % X4 before transplant

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AREVIR, Cologne 2018

p gp date 68 55 52 40 34 25 18 160 120 41 Architekt Liaison Ag Liaison Ab pos + + + + + + + + + + neg

  • 02/2013

+ + + + + + + + + + 619.53 NonReactive 56.4 06/2014 +

  • "+/-"
  • +

+ + 200.52 NonReactive 60.5 02/2015 "+/-"

  • "+/-"
  • +

+ + 154.32 NonReactive 66.4 07/2015

  • "+/-"
  • +
  • 167.61 NonReactive

50.0 12/2015

  • +
  • 97.65 NonReactive

53.9 01/2016

  • +
  • 69.91 NonReactive

43.3 04/2016

  • +
  • +
  • 77.83 NonReactive

53.6 06/2016

  • +
  • 85.07 NonReactive

52.7 08/2016

  • +
  • 09/2016
  • +
  • 05/2017
  • +
  • 79.55

01/2018

  • "+/-"
  • 57.15 NonReactive
  • 03/2018
  • ((+))
  • 49.05

WB and antibody titers

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AREVIR, Cologne 2018

ATI ???

(Analytical treatment interruption)

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AREVIR, Cologne 2018

  • HIV plasma viral load – how often, how long?

– depending on remaining size of viral reservoir – what is feasible for logistics? – what is reasonable for the patient?

  • other parameters (CD4, proviral load,…)
  • gut biopsies, lymph nodes?
  • risks of viral rebound:

– acute retroviral syndrome – increased risk of HIV transmission (partner) – tropism switch – replenishment of viral reservoir

ATI

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AREVIR, Cologne 2018

  • immediate start of ART?
  • waiting for the immune response?
  • broadly neutralising Ab?

viral rebound?

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AREVIR, Cologne 2018

Background

  • the Berlin patient – so far the only person presumed to be cured from HIV by

hematopoietic stem cell transplantation (HSCT) from a homozygous CCR5-d32 donor

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AREVIR, Cologne 2018

Background

  • the Berlin patient – so far the only person presumed to be cured from HIV by

hematopoietic stem cell transplantation (HSCT) from a homozygous CCR5-d32 donor

  • failed attempts to reproduce cure by HSCT - viral rebound or death due to

underlying malignancy

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AREVIR, Cologne 2018

The whole story (drama in 5 acts)

48y old patient, alive, well and undetectable for HIV (RNA/DNA) over 4 years after allogeneic CCR5-d32 HSCT

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AREVIR, Cologne 2018

The beginning (prologue)

induction consolidation

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AREVIR, Cologne 2018

The beginning (prologue)

induction consolidation

AML diagnosis in Jan 2011

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AREVIR, Cologne 2018

The beginning (prologue)

induction consolidation

complete remission of AML

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AREVIR, Cologne 2018

The beginning (prologue)

induction consolidation TDF/FTC/RAL to avoid interactions with chemotherapy

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AREVIR, Cologne 2018

Chapter I

.... ....

  • ne week before

SCT

female donor, 10 out of 10 HLA- matched CCR5-d32

2 cycles high-dose cytarabine

September 2012

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AREVIR, Cologne 2018

Chapter I

.... ....

  • ne week before

SCT

stem cells from female, 10/10 HLA-matched CCR5-d32 donor

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AREVIR, Cologne 2018

Chapter I

.... ....

  • ne week before

SCT

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AREVIR, Cologne 2018

Chapter II

.... during transplant and until today

  • n ART
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AREVIR, Cologne 2018

Chapter III

....

<LOD (884250) in rectal and ileum biopsy

10 10 10

+ CMV, HHV8, HSV

................ ................

2017

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AREVIR, Cologne 2018

Chapter III

....

<LOD (884250) in rectal and ileum biopsy

10 10 10

+ CMV, HHV8, HSV

+ increased liver values ................

2017

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AREVIR, Cologne 2018

Chapter III

....

<LOD (884250) in rectal and ileum biopsy

10 10 10

Tacrolimus + topical steroids + CMV, HHV8, HSV

................

2017

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AREVIR, Cologne 2018

Chapter III

....

<LOD (884250) in rectal and ileum biopsy

+ CMV, HHV8, HSV

................

2017

Tacrolimus + topical steroids

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AREVIR, Cologne 2018

Chapter III

....

<LOD (884250) in rectal and ileum biopsy

+ CMV, HHV8, HSV Tacrolimus + topical steroids

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AREVIR, Cologne 2018

Chapter V

2016

Mar Apr May Jun

ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: TCM: 0.2 Mio cells (ddPCR) – 6.7cop/106cells TEM: 0.36 Mio cells (qPCR) – 5 cop/106cells

39

month after SCT

40 41 42

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AREVIR, Cologne 2018

2016

  • G. Dunay, Hamburg:

Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: TCM: 0.2 Mio cells (ddPCR) – 6.7cop/106cells TEM: 0.36 Mio cells (qPCR) – 5 cop/106cells

Chapter V

Mar Apr May Jun

39

month after SCT

40 41 42

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AREVIR, Cologne 2018

2016

ICISTEM (J. Martinez-Picado & M. Salgado, Barcelona): qVOA: 23 Mio CD4+ T cells negative (IUPM < 0.031/106 CD4 T cells) Ileum biopsy: 0.007 Mio CD45+ cells negative (<143/106 CD45+ cells) Rectum biopsy: 0.0297 Mio CD45+ cells negative (<34/106 CD45+ cells) ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: TCM: 0.2 Mio cells (ddPCR) – 6.7cop/106cells TEM: 0.36 Mio cells (qPCR) – 5 cop/106cells

  • G. Dunay, Hamburg:

Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers

Chapter V

Mar Apr May Jun

39

month after SCT

40 41 42

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AREVIR, Cologne 2018

2016

ICISTEM (J. Martinez-Picado & M. Salgado, Barcelona): qVOA: 23 Mio CD4+ T cells negative (IUPM < 0.031/106 CD4 T cells) Ileum biopsy: 0.007 Mio CD45+ cells negative (<143/106 CD45+ cells) Rectum biopsy: 0.0297 Mio CD45+ cells negative (<34/106 CD45+ cells) ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddPCR or qPCR, but positive signals in T-cell subsets: TCM: 0.2 Mio cells (ddPCR) – 6.7cop/106cells TEM: 0.36 Mio cells (qPCR) – 5 cop/106cells

  • I. Hauber, Hamburg:

mVOA: negative in plasma, negative in histology

  • G. Dunay, Hamburg:

Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers

Chapter V

Mar Apr May Jun

39

month after SCT

40 41 42

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AREVIR, Cologne 2018

Rag#1DD Spleen Liver LN hu-CD3 HIVp24Ag

  • I. Hauber, Hamburg:

mVOA: negative in plasma, negative in histology

Chapter V

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AREVIR, Cologne 2018

# sequencing genotypic prediction phenotypic analysis in Tcells Clone gp120-V3 amino acid sequence reads FPR (%) Magi (R5/X4) MT2 (X4) D1 CTRPNNNTREGIHIGPGRAFFTTGEIIGNIREASC 4 95,78 R5 R5 D2 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIKEAYC 2 95,64 R5 R5 D3 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIGEAYC 2 95,64 R5 R5 D4 CTRPNNNTRKGIHIGPGRAFFTTGEIIGNIREASC 2062 77,33 R5 R5 D5 CTRPNNNTRKGITIGPGRAFFTTGEIIGDIRQAHC 4886 30,67 R5 R5 D6 CTRPNNNTRKGIHIGSRKAFFTTGGIIGDIRQAYC 2 10,61 R5/X4 X4 D7 CTRPHTNTRKRIHIGPGRAFFTTGEIIGDIRQAYC 7 1,74 R5/X4 X4 D8 CTKPNNNTRKRIHIGPGRAFFTTGEIIGNIRQASC 2 1,74 R5 R5 D9 CTRPNNNIRKRIHIGPGRAFFTTGEIIGNIREAYC 3 1,16 R5/X4 X4

HxB2V3Bal

control R5 51,8 R5 R5 HxB2 control X4 X4 X4

Monique Nijhuis, Utrecht, ICISTEM PHENOTYPIC CO-RECEPTOR TROPISM ANALYSIS

(sample before transplantation, PBMC)

Chapter V

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The end? (epilogue)

  • qVOA + ultra microchimerism (ICISTEM: M. Salgado, Barcelona):

lymph node (planned)

  • T-cell response assay (T. Harrer, Erlangen):

PBMCs from donor (in progress)

  • proviral DNA load from further PBMC samples and lymph node

(Institute of Virology, Cologne and others)

  • …

International collaboration to guide and investigate the potential for HIV cure by stem cell transplantation. The ICISTEM project is supported by amfAR Research Consortium on HIV eradication (ARCHE) Research Grant # 108930-56-RGRL www.icistem.org

More assays to be done:

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AREVIR, Cologne 2018

Institute for Immunogenetics, Kaiserslautern

Martin Däumer, Alex Thielen

Heinrich Pette Institut HH

Ilona Hauber, Gabor Dunay, Johanna Eberhard, Silke Kummer, Julian Schulze zur Wiesch

Med 3, University of Erlangen

Thomas Harrer

IciStem project

Annemarie Wensing, Javier Martinez-Picado, Monique Nijhuis et al.

MPI of Informatics, Saarbrücken

Thomas Lengauer, Joachim Büch, Nico Pfeifer, Alejandro Pironti, Prabhav Kalaghatgi

Thanks to our group

Institute of Virology, University of Cologne

Rolf Kaiser Eva Heger Veronica Di Cristanziano Maria Neumann-Fraune Eugen Schülter Claudia Müller Saleta Sierra-Aragon Sascha Hasheminasab

University of Düsseldorf

Hepatology & Infectiology Björn Jensen Falk Hüttig Virology Nadine Lübke Haematology Guido Kobbe Moleculare Medizin Philipp Lang Junnat Hamdam

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AREVIR, Cologne 2018

Thanks to the „Duesseldorf“ patient

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02/2013

  • pos. control
  • neg. control

06/2014 02/2015 07/2015 12/2015 01/2016

gp160 gp120 gp41 p34 p25 p18 p55 p68

Intermezzo

before SCT