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Early recovery of CMV immunity after HLA-haploidentical hematopoietic stem cell transplantation as a surrogate biomarker for a reduced risk of severe infections overall

Bone Marrow Transplantation volume 50, pages 1262–1264 (2015)Cite this article

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A major hurdle to the field of allogeneic hematopoietic stem cell transplantation (HSCT) is the lack of validated biomarkers of protective immunity against opportunistic infections, including CMV reactivation syndromes.1 This issue is particularly relevant to alternative-donor settings, for example, HLA-haploidentical HSCT (haplo-HSCT) and cord blood transplantation, where aggressive GvHD prophylaxis results in a profound and long-lasting state of immune incompetence. Despite the introduction of routine post-transplant viral monitoring and preemptive antiviral therapy, CMV reactivation syndromes remain a major cause of transplant-related mortality. Accordingly, serological evidence of prior CMV infection is still one of the main negative prognostic factors in HSCT.2 Different studies have demonstrated that a faster recovery of CMV-specific T-cell responses associates with a reduced CMV reactivation incidence in HSCT from HLA-identical sibling and matched unrelated donors.3, 4 Given its clinical and biological peculiarities, it is currently unknown whether these observations are directly translatable to the haplo-HSCT setting. In this study, while aiming to follow the recovery of CMV-specific T-cell responses after haplo-HSCT, we unexpectedly found that protective levels of CMV immunity were associated with a reduced incidence of severe infections overall.

The proportion of patients reactivating CMV or developing CMV disease at each month, until 1 year after HSCT is provided in Figure 1b. The switch from intravenous to oral antiviral therapy at day 20 possibly explains the increased CMV reactivation incidence during the second month. From the third month on, however, the CMV reactivation incidence gradually decreased, with <10% of patients experiencing CMV reactivation after 6 months. Despite that, the few CMV reactivation events recorded at later time points were clinically relevant, often causing CMV-related syndromes. In the same patients, we also evaluated the frequencies of CMV-specific T cells ex vivo at different time points post transplant. Looking for an assay that concurrently had the lowest possible detection limit, was not dependent on predefined HLA alleles and allowed the assessment of both CD4 and CD8 immunity, we gave preference to IFN-gamma Enzyme-Linked ImmunoSpot (ELISpot) after stimulation with lysates of CMV-infected fibroblasts. Using CMV-specific CD8+ CTL clones as immunological probes, we measured that infected-cell extracts allow detecting one-third of MHC-class I-restricted responses compared with cognate peptides (not shown). We however, reasoned that such a level of underestimation was well compensated by the broad repertoire of epitopes available for cross-presentation on MHC-I molecules.8 Given the high variability of CD3+ absolute counts early after transplantation, ELISpot results were normalized for the CD3 content of the PBMC sample and expressed as spot-forming cells (sfc)/μL. Using receiver operating characteristic ROC curve analysis, we found that a cutoff value of 1 CMV sfc/μL allowed discrimination with high specificity (>95%) of patients who did not reactivate the virus afterwards. At 30 days, 5/23 patients (21.7%) had a N of CMV-specific T cells >1 sfc/μL, with one developing viremia that required antiviral therapy. At 90 days, 9/31 patients (29.0%) reached this threshold, with no one developing clinically relevant viremia. Finally, at 180 days, 9/17 patients (52.9%) had a N of CMV-specific T cells >1 sfc/μL and none of them developed viremia. Overall, the true positives were 21, whereas there was only one false positive (positive predictive value, 95%). The true negatives and false negatives were 19 and 30, respectively (negative predictive value, 39%). Eighteen out of the 30 patients (60%) who did not reach the cutoff experienced infectious SAEs, mainly due to viruses (25 episodes, 65.7%), but also to other pathogens (two fungal infections, 5.3%; 6 bacterial infections, 15.8%; five unknown infections: 13.2%), compared with only 3/14 patients (21.4%) rapidly recovering CMV immunity (one viral, one bacterial and one unknown infection). After correcting for the confounding effects of disease relapse/progression by competitive-risk analysis using the R software (R-project, Vienna, Austria),9 we found that the 1-year cumulative incidence of infectious SAEs in patients recovering protective CMV immunity was significantly lower than that of patients who did not (21% vs 57%, P<0.05, Figure 1c). Vice versa, disease relapse/progression rates were not significantly different between the two groups (Figure 1d). Strikingly, none of the three patients dying from infections, including one case of fatal CMV pneumonia, achieved the protective value of 1 CMV sfc/μL.

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Acknowledgements

This work was supported by the Italian Ministry of Health (Transcan Haplo-immune Project to A Bondanza).

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Authors and Affiliations

  1. Division of Immunology, Experimental Hematology Unit, Transplantation and Infectious Diseases, San Raffaele Hospital Scientific Institute, Milan, Italy

    M Noviello, M R Carbone, Z Magnani & C Bonini

  2. Division of Regenerative Medicine, Hematology and Bone Marrow Transplantation Unit, Stem Cell and Gene Therapy, San Raffaele Hospital Scientific Institute, Milan, Italy

    A Forcina, M T L Stanghellini, M Carrabba, R Greco, L Vago, F Giglio, A Assanelli, C Corti, M Bernardi, J Peccatori & F Ciceri

  3. Vita-Salute San Raffaele University, Milan, Italy

    A Forcina, C Bordignon & A Bondanza

  4. MolMed S.p.a, Milan, Italy

    V Veronica & C Bordignon

  5. Department of Hematology, Humanitas Clinical Institute, Milan, Italy

    R Crocchiolo

  6. Division of Regenerative Medicine, Unit of Molecular and Functional Immunogenetics, Stem Cell and Gene Therapy, San Raffaele Hospital Scientific Institute, Milan, Italy

    L Vago

  7. Infectious Disease Unit, San Paolo Hospital, University of Milan, Milan, Italy

    F Crippa

  8. Division of Immunology, Innovative Immunotherapies Unit, Transplantation and Infectious Diseases, San Raffaele Hospital Scientific Institute, Milan, Italy

    A Bondanza

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  1. M Noviello
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Correspondence to A Bondanza.

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Competing interests

CB and VV are employees of MolMed S.p.a. and ChB is a consultant of MolMed S.p.a. The authors declare no conflict of interest.

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Noviello, M., Forcina, A., Veronica, V. et al. Early recovery of CMV immunity after HLA-haploidentical hematopoietic stem cell transplantation as a surrogate biomarker for a reduced risk of severe infections overall. Bone Marrow Transplant 50, 1262–1264 (2015). https://doi.org/10.1038/bmt.2015.132

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