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Quantiferon CMV assay in allogenic stem cell transplant patients
Journal of Clinical Virology 79 (2016) 10–11
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Letter to the Editor Quantiferon CMV assay in allogenic stem cell transplant patients Dear Editor, In the September 2015 issue of J. Clin. Virol., Calarota and coll. exhaustively reviewed methods for monitoring virus and non virus specific T cell response in solid organ transplantation (SOT) [1]. Principally Elispot and Quantiferon are more and more used in routine to predict risk of CMV viremia and disease [2]. Also in patients with allogeneic hematopoietic stem cell transplantation (HSCT), immunological monitoring has emerged as an important tool to target pre-emptive therapies [3]. Between January 2014 and June 2015 we conducted a prospective study to verify the clinical benefit of Quantiferon in identifying HSCT patients at risk of contracting complicated CMV infections. Quantiferon is a CE marked, ELISA based assay that measures the amount of IFN␥ secreted per volume of blood, stimulating CD8+ in 3 different tube (negative control, positive mitogen control and CMV proteins). In our study 22 patients (7 female, 15 male; aged 27–66), in the first 100 days after transplant, were monitored weekly for viremia (CMV DNA Elitech group) and twice a month for Quantiferon (Cellestis), since the reconstitution of CMV-specific T cell response is highly dynamic in early stages (3). Then both tests were conducted once a month for a year. On the basis of donor/recipients CMV serology, 5 patients
were classified as high risk (D−R+), 13 as intermediate risk (D+R+, D+R−) and 4 as low risk (D−R−). 7 patients developed Graft versus Host Disease (GvHD) ≥ 2 grade within 6 weeks after transplant. All seropositive patients had CMV first reactivation 10–48 days after transplant, but none of seronegative patients. 10 patients acquired specific CMV immunity 27–180 days after tx and 6 always remained Quantiferon negative (4 died: 42, 71, 96, 180 after tx). Immune reconstitution was obtained in proximity of CMV reactivation independently of viral load: Quantiferon positive patients before or at the same time of viral reactivation showed an average viral load of 18726 cp/ml (range <500–48431) in contrast, average viral load of negative patients was 91813 cp/ml (range 16781–175620). GvHD dramatically interfered with the timing of immune reconstitution: patients treated for GvDH developed CMV specific immunity on average after 144 days, while other patients after 57 days with more episodes of reactivation (average 5 versus 3). Patients with CMV specific immunity cleared spontaneously 67% of viremia episodes, while the same happened to only 15% of Quantiferon negative patients also in need o a longer period of antiviral therapy. From our preliminary data we can confirm that GvDH therapy delays specific immune system response against CMV. In addition we were able to identify patients who restored CD8+ functions later, had small ability to clear CMV spontaneously and reached quicker the antiviral therapy cut-off (10,000 cp/ml). Tests exploring CD4+/CD8+ asset seemed to be more stringent in identifying patients with recurrent
Table 1 Synopsis of the patients clinical data. No.
Sex
Age
Serologic serostatus HCMV (D/R)
Onset of HCMV infection (days)
Riactivation episodes (mean 2,8)
Viral load peak (copies/ml)
Quanti-FERON baseline
Time to obtain QuantiFERON Positive posttransplant (days)
Immunologic monitoring time detection (days)
Outcome
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
M F F F F M M M M M M M F M M F M M F M M M
63 66 62 51 56 60 56 55 64 53 42 61 22 46 55 61 62 47 28 38 26 39
D−/R+ D−/R+ D−/R+ D−/R+ D−/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R− D−/R− D+/R− D−/R− D−/R− D−/R−
10 14 20 33 20 16 20 8 17 48 25 25 37 12 27 30 Undetected Undetected Undetected Undetected Undetected Undetected
4 3 10 1 5 5 2 4 1 1 4 4 1 2 3 5 / / / / / /
16781 25409 31745 115325 48431 14712 48138 19469 21446 2588 32143 175000 6110 5688 <500 104232 / / / / / /
Positive Positive Positive Positive Positive Positive Positive Indet. Negative Positive Negative Positive Positive Indet. Negative Positive Negative Negative Negative Negative Indet. Indet.
Never 79 122 Never 57 27 Never 180 44 180 94 Never Never 41 38 Never Never Never Never Never Never Never
365 182 365 96 240 365 71 365 365 300 330 300 42 120 180 180 90 365 300 270 270 365
Alive Died Alive Died Alive Alive, relapse Died Alive Alive Alive Alive Alive Died Alive Alive Alive Died Alive Alive Alive Alive Alive
http://dx.doi.org/10.1016/j.jcv.2016.03.026 1386-6532/© 2016 Elsevier B.V. All rights reserved.
GvHD
x
x x x x
x x
Letter to the Editor / Journal of Clinical Virology 79 (2016) 10–11
or complicated CMV reactivations but more difficult to implement in clinical setting. In conclusion Quantiferon CMV emerges as an easy tool to introduce immunological methods in the post transplant monitoring of HSCT patients (Table 1). Funding None. Competing interest None. Ethical approval Written informed consent was obtained from patients prior to study participation. This study was approved by the Ethics Committee at Fondazione Ca’ Granda Policlinico di Milano. References [1] S.A. Calarota, J.H. Aberle, E. Puchhammer-Stockl, F. Baldanti, Approaches for monitoring of non virus-specific T-cell response in solid organ transplantation and their clinical applications, J. Clin. Virol. 70 (2015) 109–119, http://dx.doi. org/10.1016/j.jcv.2015.07.299. [2] T. Flaming, J. Dunne, B. Crowley, Ex vivo monitoring of human cytomegalovirus-specific CD8(+) T-Cell responses using the QuantiFERON-CMV assay in allogeneic hematopoietic stem cell transplant recipients attending an Irish hospital, J. Med. Virol. 82 (3) (2010) 433–440, http://dx.doi.org/10.1002/ jmv.21727. [3] T. Siok-Keen, G.A. Kennedy, D. Cromer, M.P. Davemport, S. Walker, L.I. Jones, Clinical assessment of a anti-viral CD8 + cell immune monitoring using Quantiferon-CMV assay to identify high risk allogenic stem cell transplant patients with CMV infections complications, PLoS One 8 (2013) e74744, http:// dx.doi.org/10.1371/journal.pone.0074744.
11
Patrizia Bono Anna Orlandi Antonella Zoccoli Alberto Salvatore UOS Virologia Fondazione Ca’ Granda Policlinico, Milano, Italy Claudio Annaloro Elena Tagliaferri Centro Trapianto Midollo Fondazione Ca’ Granda Policlinico, Milano, Italy Giovanna Lunghi ∗ UOS Virologia Fondazione Ca’ Granda Policlinico, Milano, Italy ∗ Corresponding author. E-mail addresses: [email protected] (P. Bono), [email protected] (A. Orlandi), [email protected] (A. Zoccoli), [email protected] (A. Salvatore), [email protected] (C. Annaloro), [email protected] (E. Tagliaferri), [email protected] (G. Lunghi).
30 December 2015 23 February 2016 27 March 2016
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Letter to the Editor Quantiferon CMV assay in allogenic stem cell transplant patients Dear Editor, In the September 2015 issue of J. Clin. Virol., Calarota and coll. exhaustively reviewed methods for monitoring virus and non virus specific T cell response in solid organ transplantation (SOT) [1]. Principally Elispot and Quantiferon are more and more used in routine to predict risk of CMV viremia and disease [2]. Also in patients with allogeneic hematopoietic stem cell transplantation (HSCT), immunological monitoring has emerged as an important tool to target pre-emptive therapies [3]. Between January 2014 and June 2015 we conducted a prospective study to verify the clinical benefit of Quantiferon in identifying HSCT patients at risk of contracting complicated CMV infections. Quantiferon is a CE marked, ELISA based assay that measures the amount of IFN␥ secreted per volume of blood, stimulating CD8+ in 3 different tube (negative control, positive mitogen control and CMV proteins). In our study 22 patients (7 female, 15 male; aged 27–66), in the first 100 days after transplant, were monitored weekly for viremia (CMV DNA Elitech group) and twice a month for Quantiferon (Cellestis), since the reconstitution of CMV-specific T cell response is highly dynamic in early stages (3). Then both tests were conducted once a month for a year. On the basis of donor/recipients CMV serology, 5 patients
were classified as high risk (D−R+), 13 as intermediate risk (D+R+, D+R−) and 4 as low risk (D−R−). 7 patients developed Graft versus Host Disease (GvHD) ≥ 2 grade within 6 weeks after transplant. All seropositive patients had CMV first reactivation 10–48 days after transplant, but none of seronegative patients. 10 patients acquired specific CMV immunity 27–180 days after tx and 6 always remained Quantiferon negative (4 died: 42, 71, 96, 180 after tx). Immune reconstitution was obtained in proximity of CMV reactivation independently of viral load: Quantiferon positive patients before or at the same time of viral reactivation showed an average viral load of 18726 cp/ml (range <500–48431) in contrast, average viral load of negative patients was 91813 cp/ml (range 16781–175620). GvHD dramatically interfered with the timing of immune reconstitution: patients treated for GvDH developed CMV specific immunity on average after 144 days, while other patients after 57 days with more episodes of reactivation (average 5 versus 3). Patients with CMV specific immunity cleared spontaneously 67% of viremia episodes, while the same happened to only 15% of Quantiferon negative patients also in need o a longer period of antiviral therapy. From our preliminary data we can confirm that GvDH therapy delays specific immune system response against CMV. In addition we were able to identify patients who restored CD8+ functions later, had small ability to clear CMV spontaneously and reached quicker the antiviral therapy cut-off (10,000 cp/ml). Tests exploring CD4+/CD8+ asset seemed to be more stringent in identifying patients with recurrent
Table 1 Synopsis of the patients clinical data. No.
Sex
Age
Serologic serostatus HCMV (D/R)
Onset of HCMV infection (days)
Riactivation episodes (mean 2,8)
Viral load peak (copies/ml)
Quanti-FERON baseline
Time to obtain QuantiFERON Positive posttransplant (days)
Immunologic monitoring time detection (days)
Outcome
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
M F F F F M M M M M M M F M M F M M F M M M
63 66 62 51 56 60 56 55 64 53 42 61 22 46 55 61 62 47 28 38 26 39
D−/R+ D−/R+ D−/R+ D−/R+ D−/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R+ D+/R− D−/R− D+/R− D−/R− D−/R− D−/R−
10 14 20 33 20 16 20 8 17 48 25 25 37 12 27 30 Undetected Undetected Undetected Undetected Undetected Undetected
4 3 10 1 5 5 2 4 1 1 4 4 1 2 3 5 / / / / / /
16781 25409 31745 115325 48431 14712 48138 19469 21446 2588 32143 175000 6110 5688 <500 104232 / / / / / /
Positive Positive Positive Positive Positive Positive Positive Indet. Negative Positive Negative Positive Positive Indet. Negative Positive Negative Negative Negative Negative Indet. Indet.
Never 79 122 Never 57 27 Never 180 44 180 94 Never Never 41 38 Never Never Never Never Never Never Never
365 182 365 96 240 365 71 365 365 300 330 300 42 120 180 180 90 365 300 270 270 365
Alive Died Alive Died Alive Alive, relapse Died Alive Alive Alive Alive Alive Died Alive Alive Alive Died Alive Alive Alive Alive Alive
http://dx.doi.org/10.1016/j.jcv.2016.03.026 1386-6532/© 2016 Elsevier B.V. All rights reserved.
GvHD
x
x x x x
x x
Letter to the Editor / Journal of Clinical Virology 79 (2016) 10–11
or complicated CMV reactivations but more difficult to implement in clinical setting. In conclusion Quantiferon CMV emerges as an easy tool to introduce immunological methods in the post transplant monitoring of HSCT patients (Table 1). Funding None. Competing interest None. Ethical approval Written informed consent was obtained from patients prior to study participation. This study was approved by the Ethics Committee at Fondazione Ca’ Granda Policlinico di Milano. References [1] S.A. Calarota, J.H. Aberle, E. Puchhammer-Stockl, F. Baldanti, Approaches for monitoring of non virus-specific T-cell response in solid organ transplantation and their clinical applications, J. Clin. Virol. 70 (2015) 109–119, http://dx.doi. org/10.1016/j.jcv.2015.07.299. [2] T. Flaming, J. Dunne, B. Crowley, Ex vivo monitoring of human cytomegalovirus-specific CD8(+) T-Cell responses using the QuantiFERON-CMV assay in allogeneic hematopoietic stem cell transplant recipients attending an Irish hospital, J. Med. Virol. 82 (3) (2010) 433–440, http://dx.doi.org/10.1002/ jmv.21727. [3] T. Siok-Keen, G.A. Kennedy, D. Cromer, M.P. Davemport, S. Walker, L.I. Jones, Clinical assessment of a anti-viral CD8 + cell immune monitoring using Quantiferon-CMV assay to identify high risk allogenic stem cell transplant patients with CMV infections complications, PLoS One 8 (2013) e74744, http:// dx.doi.org/10.1371/journal.pone.0074744.
11
Patrizia Bono Anna Orlandi Antonella Zoccoli Alberto Salvatore UOS Virologia Fondazione Ca’ Granda Policlinico, Milano, Italy Claudio Annaloro Elena Tagliaferri Centro Trapianto Midollo Fondazione Ca’ Granda Policlinico, Milano, Italy Giovanna Lunghi ∗ UOS Virologia Fondazione Ca’ Granda Policlinico, Milano, Italy ∗ Corresponding author. E-mail addresses: [email protected] (P. Bono), [email protected] (A. Orlandi), [email protected] (A. Zoccoli), [email protected] (A. Salvatore), [email protected] (C. Annaloro), [email protected] (E. Tagliaferri), [email protected] (G. Lunghi).
30 December 2015 23 February 2016 27 March 2016