CMV Seronegativity Research Articles

Double Umbilical Cord Blood Transplantation Offers Stable Donor Engraftment and The Prospect Of Cure In Adult Patients With High-Risk Hematologic Malignancies

Allogeneic stem cell transplantation (allo-SCT) remains the main therapeutic option for patients with high-risk hematologic malignancies, albeit with the requirement of a properly matched and timely available donor. Dual-unit umbilical cord blood transplantation (dUCBT) has become an alternative modality, which offers immediate access to allo-SCT for most adult patients who lack an appropriate volunteer donor.We retrospectively analyzed the outcomes of consecutive dUCBT procedures that were undertaken by our center over a seven-year period, with focus on factors affecting engraftment and survival.Between 2006 and 2013, 40 patients underwent dUCBT at a median age of 37 years (range, 16-60) for various hematologic malignancies (acute myeloid leukemia: 22, myelodysplastic syndrome: 5, chronic myelogenous leukemia: 2, acute lymphoblastic leukemia: 6, mixed-phenotype acute leukemia: 2, plasmacytoid dendritic cell neoplasm: 1, hepatosplenic T cell lymphoma: 1, chronic lymphocytic leukemia: 1). The majority of patients (73.7%) had advanced or intermediate-phase disease at the time of transplantation, with a median time from diagnosis to transplant of 17.7 months (range:3.1-92.3). Recipient body weight ranged from 48 to 110 kg (median, 73). The conditioning regimen was myeloablative in 33 (82.5%) patients (busulfan-based in 22, and total body irradiation-based in 11 cases). Antithymocyte globulin was not administered during conditioning, with the exception of one case.Most units (55/80, 68.75%) were 4/6 antigen matched to recipient at HLA-A, -B, and -DRB1 loci, and the remaining were 5/6 matched. By retrospective high-resolution typing for class I HLA alleles, histocompatibility was demoted in 62.3% of units. By additional allele-level typing at HLA-C and -DQB1 loci, the degree of compatibility varied from 8/10 to 3/10, with 80.5% of the units being ≤6/10 matched to the patient. The median dose of cryopreserved total nucleated cells (TNC) per unit was 2.53 x 107/kg (range, 1.09-5.66). At infusion, patients received in total a median of 4.55 x 107 TNC/kg (range, 2.65-9.3) and 1.7 x 105CD34+ cells/kg (range, 0.54-5.14) from both units.The cumulative incidence (CI) of neutrophil engraftment was 92.5% (37/40 patients), with achievement of an absolute neutrophil count (ANC) greater than 500/uL at a median of 20 days (range, 12-52) (Figure 1). Platelet recovery (>50x109/L) occurred at a CI of 63.2%, and a median time of 84 days (range, 32-363). No influence of cell dose (TNC or CD34+) or of the degree of HLA match on the incidence and kinetics of engraftment could be detected. Acute graft-versus-host disease (aGVHD) of grades II-IV and III-IV developed in 85% and 12.65% of patients, respectively. The CI of chronic GVHD was 31% (extensive in 54.5% of cases). There was a statistical trend for increased incidence of cGVHD with <6/10 HLA match at the allele level (p=0.068; HR, 3.35; 95% confidence interval [ci], 0.92-12.24). Non-relapse mortality (NRM) reached 43.1% (95% ci, 27.0-58.2) at 10.3 months, but no case of NRM was noted thereafter (Figure 2). Major causes of NRM were infection/sepsis (n=11), GVHD (n=3), and engraftment failure (n=3). The CI of relapse was 22.7% (95% ci, 10.7-37.5). Relapse was the cause of death of 6 patients. With a median follow-up of 30 months (range, 2-84), overall (OS) and disease-free survival (DFS) rates at 2 years were 36.5% (95% ci, 21-52) and 34.2% (95% ci, 19.3-49.6), respectively (Figure 3). Sixteen of 40 patients are alive and disease-free for a median time of 30 months from transplant. Age ≤37 years, recipient CMV seronegativity, and early disease phase at transplant were associated with improved OS in univariate analysis. Age remained as the only independent risk factor for OS in multivariate analysis of OS (p=0.022). Age ≤37 years was also found to be associated with reduced NRM (p=0.055), and favorable DFS (p=0.04). [Display omitted] [Display omitted] [Display omitted] In conclusion, dUCBT can lead to stable donor engraftment even across multiple HLA disparities and can overcome the barrier of cell dose. Despite considerable early mortality, dUCBT offers the possibility of long-term survival in about one third of adult patients with poor-prognosis hematologic malignancies, for whom allo-SCT would not be otherwise feasible. Disclosures:No relevant conflicts of interest to declare.

Reduced intensity-conditioned allogeneic stem cell transplantation for multiple myeloma relapsing or progressing after autologous transplantation: a study by the European Group for Blood and Marrow Transplantation

Outcomes and prognostic factors of reduced intensity-conditioned allo-SCT (RIC allo-SCT) for multiple myeloma (MM) relapsing or progressing after prior autologous (auto)-SCT are not well defined. We performed an analysis of 413 MM patients who received a related or unrelated RIC allo-SCT for the treatment of relapse/progression after prior auto-SCT. Median age at RIC allo-SCT was 54.1 years, and 44.6% of patients had undergone two or more prior auto-SCTs. Median OS and PFS from the time of RIC allo-SCT for the entire population were 24.7 and 9.6 months, respectively. Cumulative non-relapse mortality (NRM) at 1 year was 21.5%. In multivariate analysis, CMV seronegativity of both patient and donor was associated with significantly better PFS, OS and NRM. Patient-donor gender mismatch was associated with better PFS, fewer than two prior auto-SCT was associated with better OS, and shorter time from the first auto-SCT to the RIC allo-SCT was associated with lower NRM. The results of this study identify patient and donor CMV seronegativity as the key prognostic factor for outcome after RIC allo-SCT for MM relapsing or progressing after prior auto-SCT.

Double-Unit Cord Blood Transplantation (DCBT) for Acute Leukemia: High Disease-Free Survival in Adults and Children with Comparable Survival in European and Minority Patients

Abstract 3080As compared to single-unit CBT, DCBT may improve engraftment and protect against relapse. Therefore, we have adopted DCBT for both children and adults with acute leukemia, myelodysplasia (MDS), and myeloproliferative diseases (MPD). However, determinants of disease-free survival (DFS) have yet to be fully established. Furthermore, whether DFS after DCBT is comparable in patients of European and non-European ancestry is of special interest. Therefore, we analyzed the DFS of 75 DCBT recipients with acute leukemia in morphologic remission or aplasia (n = 69), and MDS/MPD with ≤ 5% blasts (n = 6) transplanted from 10/2005-4/2011. Nearly all patients had high-risk disease. Children 0–15 years (n = 23) had the following characteristics: median age 9 years (range 0.9–15); median weight 37 kg (range 7–72); 30% European; and 26% CMV sero-positive. Diagnoses were 43% AML (or biphenotypic), 52% ALL, and 4% MDS/MPD, and all received high-dose conditioning. The children received grafts with a median infused TNC × 107/kg of 3.3 (larger unit) and 2.6 (smaller unit), and 2% of units were 6/6 HLA-A, -B antigen, -DRB1 allele matched, 63% 5/6, and 35% 4/6. Adults ≥ 16 years (n = 52) had the following characteristics: median age 41 years (range 16–69); median weight 69 kg (range 47–105); 48% European; 69% CMV sero-positive; and diagnoses were 63% AML (or biphenotypic), 27% ALL, and 10% MDS/MPD. Fifty percent received high-dose and 50% reduced intensity conditioning. Their units had a median infused TNC/kg of 2.7 and 1.9, and 3% were 6/6 HLA-matched, 47% 5/6, and 50% 4/6. All patients (pediatric and adult) received calcineurin-inhibitor/ mycophenolate mofetil immunosuppression, and none received anti-thymocyte globulin. Sustained donor neutrophil engraftment was seen in 91% of children and 94% of adults at medians of 20 and 26 days, respectively. The incidence of grade II-IV acute GVHD by day 180 was 44% in children and 58% in adults. Day 100 transplant-related mortality (TRM) was 9% in children and 19% in adults. The 2-year relapse incidence was 9% in children and 6% in adults. With a median follow-up of survivors of 26 months (range 4–70), 2-year Kaplan-Meier estimate of DFS was 78% in children and 64% in adults (Figure). Differences in survival by age did not reach significance. Univariate analysis of variables potentially influencing 2-year DFS (with log rank estimates of significance) in all patients is shown in the Table. There were no differences in 2-year DFS according to ancestry, remission status, and conditioning intensity. There was also no difference in 2-year DFS according to engrafting unit-recipient HLA-match (4-6/6 or 10 allele), or engrafting unit infused TNC dose/kg. However, patients who were CMV seronegative had a higher 2-year DFS (85% vs 55%, p = 0.018). Multivariate analysis revealed recipient CMV serostatus was a predictor of DFS independent of patient age, and its effect was mediated by an influence on TRM. We have previously shown that DCBT extends transplant access to minority patients. We now demonstrate that DCBT can achieve high and comparable DFS in both European and non-European pediatric and adult patients with acute leukemia and MDS/MPD. While these are very encouraging results further investigation in racial/ethnic sub-groups is needed. Nonetheless, our findings support DCBT as an immediate alternative therapy for high-risk acute leukemia in patients without suitable unrelated volunteer donors, especially given the very low incidence of relapse. [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Increased activity and improved outcome in unrelated donor haemopoietic cell transplants for acute myeloid leukaemia in Australia, 1992–2005

Numbers of unrelated donor allogeneic haemopoietic cell transplants (HCT) for acute myeloid leukaemia have increased in Australia in recent years. The aims of this study were to investigate the components of this change and find contributing factors to changes in outcome. The study method was a retrospective analysis of 213 consecutive first unrelated donor HCT for acute myeloid leukaemia performed within Australia for adult patients during the years of 1992-1997 (n= 43) and 1998-2005 (n= 170). The proportion of patients transplanted in first or second complete remission (CR) increased markedly from 21% in 1992-1997 to 52% in 1998-2005. The cumulative incidence of relapse at 1 year post HCT was significantly lower for the later cohort (22% vs 30%, P= 0.04) and for patients transplanted in CR compared with those not in CR (16% vs 31%, P= 0.01). The overall survival probability was significantly better at 5 years post HCT for patients transplanted in 1998-2005 compared with 1992-1997 (40% vs 21%, P= 0.04). Multivariate analysis identified five independent significant favourable factors for survival among the whole patient group: age under 40 years, transplant in CR1, CR2 or first relapse, patient CMV seronegativity, good performance status and year of transplant within 1998-2005. The later cohort of patients had improved survival even after allowing for the effects of age, remission status and other factors, which suggests a general improvement in the safety of the procedure over time, particularly for patients in early disease stages at transplant.

80: Primary CMV Infection in CMV Seronegative Recipients of a Stem Cell Product from a Seropositive Donor (D+/R-): Frequency of and Risk Factors for Transmission

80: Primary CMV Infection in CMV Seronegative Recipients of a Stem Cell Product from a Seropositive Donor (D+/R-): Frequency of and Risk Factors for Transmission

Matching for 12 HLA Alleles Is Associated with a Significantly Superior Survival Due to a Lower Mortality in Recipients of Unrelated Donor Haematopoietic Cell Transplants for Early but Not Late Stage Leukaemia.

Recipient/donor HLA matching is an important determinant of outcome in transplantation using volunteer unrelated donor (VUD). The degree of matching remains controversial. Some data suggest that disease stage is an important factor to consider when assessing the need for a well-matched donor. We analysed the impact of matching for 12 HLA alleles at six loci (HLA-A, -B, -C, -DRB1, -DQB1, -DPB1) in a cohort of 458 patients receiving VUD transplants for leukaemia (142 CML, 170 AML, 146 ALL). Of the pairs, 84 were matched for 12/12 alleles, 250 and 124 were mismatched for one locus or more than one locus respectively (graft versus host vector). Most single locus mismatches were at DPB1 (218/250, 87%). In multiply mismatched pairs the loci were: DPB1 plus one other locus (81), 2 other loci excluding DPB1 (10) and more than 2 loci (33). Patients receiving 12/12 matched grafts had a significantly better survival than those who had mismatched grafts (7 years: 45% vs 30%, p=0.022) and those matched for 10/10 alleles (p=0.050). The outcome was not significantly different dependent on whether the mismatch was at single or multiple loci, nor whether the single mismatch was at DPB1 compared to any other HLA locus. Disease stage was a significant determinant of outcome, with patients transplanted in early stage disease (defined as CR1 or CP1, N=222) having a superior outcome to those with late stage disease (N=236) (7 year: 42% vs 28%; p=0.002) In patients with early stage disease, the survival was significantly better if 12/12 matched compared to the mismatched group (7 years: 62% vs 36%; p=0.005). Other factors associated with a significantly improved survival in this cohort were: patient age below the median (32 years), patient CMV seronegativity and CML (rather than acute leukaemia). In multivariate analysis, pairs matched for less than 12/12 HLA alleles (HR=1.8; CI 1.0–3.0; p=0.034) and acute leukaemia (HR=1.8; CI 1.2–2.6; p=0.003) had a significantly worse survival. The reason for the inferior outcome was a significantly worse transplant related mortality (TRM) in the mismatched pairs (p=0.006). This was 16%, 32% and 48% at 100 days, 1 and 7 years in the mismatched group, compared to 9%, 13% and 21% in the matched group. While the incidence of acute graft versus host disease (GvHD) overall was not increased in the mismatched group, the incidence of grade III/IV GvHD was higher (12/12 match = 0%, single locus mismatch = 2%, multiple loci=13%; p=0.002) and this was associated with a higher TRM (p=0.002). There was no significant impact of mismatching on chronic GvHD or disease relapse. Unlike these data, in the late disease stage cohort there was no effect of 12/12 matching status on survival (7 years: 25% vs 28%, NS) or TRM. However, there was an increase in GvHD in HLA mismatched pairs (acute, p=0.012; chronic, p=0.015) and the presence of cGvHD was protective against disease relapse (p=0.044). These data suggest that in patients transplanted at an early disease stage, matching for 12 HLA alleles is important to improve survival. In later stage disease the presence of an HLA mismatch may increase the incidence of GvHD and consequently of the graft versus leukaemia effect and hence be tolerated overall.

Impact of HLA class I and class II DNA high-resolution HLA typing on clinical outcome in adult unrelated stem cell transplantation after in vivo T-cell depletion with alemtuzumab

Survival after volunteer unrelated donor (VUD) stem cell transplantation (SCT) is influenced by matching for human leucocyte antigens (HLA). We analysed the effects of serological and molecular typing at HLA-A, -B, -C and -DRB1 in 100 patient/VUD pairs from a single transplant centre. Patients received SCT for good risk [chronic myeloid leukaemia in first chronic phase (CML-CP1), n = 55] or poor risk ( n = 45) diseases after myeloablative conditioning and T-cell depletion with alemtuzumab. By serological typing, 70 pairs were fully matched, whereas molecular typing revealed 10 pairs with additional mismatches. The day 100 transplant related mortality was 15%. Acute graft versus host disease (GvHD) grades III–IV occurred in 11%, whilst extensive chronic GvHD in 13% of evaluable patients. There was no statistical difference in GvHD rates between patients who received grafts from fully matched or from mismatched donors. In univariate analysis the disease risk group and CMV seronegativity of recipient and donor were the only significant predictors for survival, with 3-year survival probabilities of 71.2% for CML-CP1 and 28% for poor risk diseases. In the poor risk group, HLA mismatches had a negative impact on survival ( p = 0.003) and progression free survival ( p = 0.009) contrary to CML-CP1 patients, in whom HLA mismatches at molecular or serological level did not have any impact.

Volunteer Unrelated Donor PBSC Collection Efficacy and Recipient Outcomes: Results of a Prospective National Marrow Donor Program (NMDP) Trial, 1999–2003.

In spite of limited multi-institutional outcome data and concern about high rates of chronic GVHD, PBSC has become the most frequently used unrelated donor stem cell source. We present an analysis of 1178 non-T-cell depleted donor/recipient pairs enrolled on a prospective trial conducted by the NMDP (1999–2003; med f/u 762 d). Multivariate analysis revealed that younger donors, heavier donors, or donors with higher pre-apheresis CD34+ cell numbers gave significantly higher CD34+ yields. The median time to neutrophil and platelet engraftment >50K was 14 and 24 days, respectively. Recipients were more likely to have neutrophil engraftment by day 25 if the pre-BMT Karnofsky score was ≥90 (OR 0.31 for <90, p<0.001) or if the donor blood volume processed was about 24 L (OR 2.88 for 24L vs. <19L, p=0.006). Recipients were more likely to engraft platelets by day 60 if their Karnofsky score was ≥90 (OR 0.66 for <90, p=0.006), they were CMV seronegative (OR 0.66 for CMV+, p=0.004) or the number of CD34+ cells/kg recipient wt in the infused product was higher (OR 2.94 for >9.5x106 CD34+ cells/kg vs <3.6, p<0.001). Surprisingly, a higher incidence of grade II-IV aGvHD at 100 days was noted in pediatric compared to adult patients (58% vs. 45%, p = 0.009), although rates of grade III-IV aGvHD were similar (31 vs. 26%, p= 0.28). Adjustment for the lower rate of reduced intensity conditioning (RIC) performed in children (15% vs. 45%) plus a higher mismatch rate (14% vs. 10%) explained some but not all of this effect (RR decreased from 1.62 to 1.29). Lower rates of grade II-IV aGVHD were also noted for HLA matched vs mismatched (45 vs. 56%, p = 0.017), and RIC vs. myeloablative patients (39 vs. 51%, p < 0.0001). FK506 was superior to CsA-based regimens in preventing grade II-IV aGvHD (RR 0.73, p=0.003). Of note, higher total WBC in the infused product was found to be associated with a lower risk of developing grade III-IV aGvHD (<45 x 109 vs ≥ 91 x 109, RR 0.64, p=0.009). Among 565 recipients who developed cGvHD (cumulative incidence 50% in adult and 58% in pediatric recipients at 2 yrs), 110 (19%) had limited and 455 (81%) extensive involvement. Chronic GvHD occurred more often with CsA vs. FK506 (RR 0.64 for FK506, p<0.001). An advantage in survival at one year was noted for early vs. intermediate vs. high risk disease (1yr OS 57 vs. 45 vs. 33%, p < 0.0001) and 6/6 HLA matched vs. mismatched groups (1yr OS 48 vs. 38%, p = 0.007). At latest follow up, the risk of dying was higher in recipients who had a Karnofsky score <90 (RR 1.56, p<0.001), were CMV seropositive (RR 1.23, p=0.006), had an HLA-mismatched donor (RR 1.46, p=0.001), or received a myeloablative transplant (RIC RR 0.73, p<0.001). In addition, smaller product volume or lower platelet count in the product also resulted in poorer survival (high vs. low RR of 0.70 (volume ) and 0.82 (platelets), p=0.005). In conclusion, unrelated donor PBSC results in rapid engraftment and acceptable long-term survival outcomes, but cGVHD occurs in >50% of recipients. Better outcomes are associated with use of FK-506, 24L of collection, higher product cell counts, RIC regimens, matched donors, low risk disease and high Karnofsky scores. Pediatric recipients have similar or worse GvHD outcomes compared to adults.

Case–control study of risk factors for the development of post‐transplant lymphoproliferative disease in a pediatric heart transplant cohort*

PTLD is an important complication following heart transplantation. To better define the risk factors of PTLD in children, we performed a case-control study. All pediatric cardiac transplant recipients who developed their first episode of PTLD were matched by age (+/-1 yr) and time since transplant (+/-1 yr) with those who did not. PTLD occurred in nine of 95 cardiac transplant recipients (9%), 0.3-7.8 yr following cardiac transplantation (median = 2.5 yr). Patients were 0.1-16.4 yr (median = 3.7) at transplantation. Biopsies revealed polymorphic B cell hyperplasia (three), polymorphic B cell lymphoma (one), monomorphic diffuse large cell B cell lymphoma (three) and monomorphic Burkitt's-like lymphoma (two). Patients who developed PTLD were at no greater risk of death (p = 0.31). Recipient EBV seronegativity at time of transplant (p = 0.08), EBV seroconversion (p = 0.013) and recipient CMV seronegativity (p = 0.015) were associated with the development of PTLD by conditional logistic regression; sex, race, donor age, recipient diagnosis, donor CMV seropositivity, recipient treatment for CMV infection, EBV seropositivity at the time of PTLD diagnosis, and number of rejection episodes, treated rejection episodes, and lympholytics used were not. There was no significant association between PTLD and death in our recipients. EBV seroconversion and recipient CMV seronegativity were associated with the development of PTLD.

Etiology and impact of cytomegalovirus disease on solid organ transplant recipients

The characteristics, etiology, natural history, and direct and indirect effects of CMV disease in solid organ transplant recipients are described. CMV is a common herpesvirus that may be present in the donor or recipient of a solid organ transplant. Even though it is rarely pathogenic in healthy patients, transplant recipients are at risk for CMV viremia and symptomatic disease due to their immune-suppressed status. In addition to symptoms directly attributed to active disease, CMV can have a variety of indirect effects. Indirect effects may include additional infectious complications, posttransplant lymphoproliferative disease, allograft rejection, allograft loss, or death. The three most prevalent risk factors for CMV infection are CMV seronegativity in a recipient of an organ from a CMV-seropositive donor, the type of organ transplanted, and the degree of immune suppression. CMV prophylaxis is effective at preventing disease, but may result in a delayed onset where CMV disease occurs once the prophylaxis is stopped. Knowledge of risk factors for CMV infection and disease, the natural history in transplant recipients, and its direct and indirect effects will help clinicians make appropriate decisions regarding the use of preventive strategies.

Multiple Transplant-Related Risk Factors for Hemolysis Including Major Kidd-Group Incompatibility Did Not Influence the Favourable Course of Unrelated Donor Bone Marrow Transplantation for Paroxysmal Nocturnal Hemoglobinuria.

The significance of additional transplant-related risk factors for hemolysis, including potentially severe hemolysis due to Kidd group incompatibility, is unknown in BMT from matched unrelated donors (MUD). We report MUD BMT for 35y old male PNH patient (pt) diagnosed 1,5y before, with CD59 defect on 95% of erythrocytes (Er), with refractory hemolysis (LDH 1886 U/l, haptoglobin 0.08 g/l) and IgG autoantibodies on Er, previously treated with steroids and multiple transfusions with increasing frequency. BMT-related risk factors for hemolysis were: major Kidd incompatibility (Jk(b)+ donor and detectable anti-Jk(b) alloantibodies in titer 2 in pt), minor AB0 incompatibility (pt B, donor 0 with anti-B titer 1:16) and different Rh (pt−, donor+). Other risk factors included CMV seronegativity of the donor and seropositivity of the pt, arterial hypertension, steroid-related diabetes mellitus and probable former thrombotic episode leading to nasal septum perforation. MUD was ten alleles HLA-matched 38y old male. Myeloablative conditioning consisted of Treosulfan, Fludarabine and Thymoglobulin. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporin-A and methotrexate. Gancyclovir and IgG were used for CMV-reactivation prophylaxis. Transplanted bone marrow was depleted of Er on Fenwall CS3000 plus and contained 0.5x10(8) NC/kg, 2.1x10(6) CD34+ cells/kg and 12.5x10(6) CD3+ cells/kg. No serious complications were observed during the treatment and post-transplant aplasia. Filtered washed Er 0Rh-Jk(b)- were transfused 7x and single-donor platelets 7x. Following 11 days of absolute agranulocytosis full reconstitution of haematopoiesis was achieved with granulocyte count of 1.0x10(9)/l and platelets 50x10(9)/l on day +22, Hb 10 g/dl on day +26. Acute GVHD grade II was transiently present since day +21 and responded well to low-dose methylprednisolone. No chronic GVHD was observed. CMV reactivation with transient severe pancytopenia developed after day +70 and was overcome with ganciclovir, foscarnet and immunoglobulins. Hemolysis gradually decreased (LDH less than 400 U/L since day +5, normal haptoglobin >0.7 g/l since day +38). Anti-Jk(b) alloantibodies titer reached 0 on day +31 and since then they were detectable only with use of a micro-method. Full 100% donor chimerism was achieved on day +28 and was re-confirmed on days +71 and +99. Recipient-type population of erythrocytes gradually decreased (24%, 7% and 1% on days +30, +70 and +98, respectively). Complete eradication of PNH clone was confirmed by absence of complement inhibitor CD55 (DAF) and CD59 (MIRL) defects on 100% of erythrocytes and granulocytes in flow-cytometric evaluation performed on day +160. The patient stays at home without any signs of GVHD, hemolysis nor PNH over 9 months following BMT. We conclude that MUD BMT can be offered as an effective treatment option despite multiple transplant-related risk factors for hemolysis including Kidd group incompatibility.

Hemolytic Uremic Syndrome after Bone Marrow Transplantation: Clinical Characteristics and Outcome in Children

Hemolytic uremic syndrome (HUS) is an uncommon but potentially life-threatening complication of hematopoietic stem cell transplantation. We retrospectively studied the medical records of 293 children who underwent allogeneic bone marrow transplantation at St. Jude Children’s Research Hospital between 1992 and 1999 to describe the clinical course of and to identify risk factors for transplant-associated HUS. Conditioning regimens included cyclophosphamide, cytarabine, and total body irradiation for patients with hematologic malignancies (n = 244); patients with nonmalignant diseases (n = 49) received disease-specific regimens. Grafts from unrelated or mismatched related donors were depleted of T lymphocytes, whereas matched sibling grafts were unmanipulated. All patients received cyclosporine as prophylaxis for graft-versus-host disease. Recipients of grafts from matched siblings also received pentoxifylline or short-course methotrexate. HUS developed in 28 (9.6%) patients at a median of 171 days after transplantation. We identified older donor age ( P = .029), use of antithymocyte globulin in the conditioning regimen ( P = .008), and recipient CMV seronegativity ( P = .011) as being associated with an increased risk of HUS. With a multiple regression analysis, the use of antithymocyte globulin (β = .86; P = .04) and recipient cytomegalovirus seronegativity (β = .93; P = .035) remained significant risk factors for the development of HUS.

Multivariate Analysis of the Influence of Donor and Recipient Cytomegalovirus Sero-Pairing on Outcomes in Simultaneous Kidney-Pancreas Transplantation: The South-Eastern Organ Procurement Foundation Experience

The purpose of this study was to determine if donor (D) and recipient (R) CMV sero-pairing at the time of simultaneous kidney-pancreas transplantation (SKPT) subsequently influenced outcomes in a large cohort of patients with long-term follow-up. Between January 1, 1997 and December 31, 1999 complete data were available on 723 primary SKPTs performed at South-Eastern Organ Procurement Foundation member institutions. For purposes of this study, four groups were defined: D+/R−, n = 203 (28%); D+/R+, n = 206 (28%); D−/R+, n = 156 (22%); and D−/R−, n = 158 (22%). Patient and graft survival rates for the study groups were computed by Kaplan-Meier estimates and tests of equality of survival curves were performed utilizing both the log-rank and Wilcoxon test statistics. A multivariate analysis was performed using a Cox proportional hazards model and logistic regression. A total of 56% of Ds were CMV+ and 50% of Rs were CMV−. D serostatus was not, but R serostatus was, a significant independent risk factor for patient and kidney, but not pancreas, graft survival rates in the uncensored analysis. When examining the CMV D/R groups in both univariate and multivariate fashion, CMV sero-pairing was not an independent risk factor for death, graft loss, or rejection. However, when considering CMV sero-pairing as a binary variable (D−/R− versus all other D/R groups), 6-year patient, kidney, and pancreas graft survival rates were significantly higher in the D−/R− group ( P < .05). In conclusion, CMV seronegativity is present in half of diabetic patients at the time of SKPT, and protective CMV seronegative matching confers a long-term survival advantage.

Cytomegalovirus Infections Following Reduced-Intensity Allogeneic Stem Cell Transplantation.

Reduced intensity allogeneic stem cell transplantation is increasingly used for patients who are at high risk for mortality following conventional full-intensity regimens. Defining the risk of CMV-related events in this growing modality has a significant implication in future immunologic interventions to improve their transplant outcomes. Therefore, we analyzed 160 patients at risk for CMV (R+ and/or D+) who received a reduced intensity transplant (RIT) between May 2000 and February 2004 from either a matched-related (n=91) or unrelaed donor (n=69) under the City of Hope IRB protocol #02047. The median age of the cohort was 51 (range: 15–71) and recipient/donor CMV serostatus was; R+D+=87, R+D-=44, R-D+=29. Conditioning regimens were reduced but myeloablative (fludarabine + melphalan or busulfan) in 124 or truly non-myeloablative (TBI 200cGy +/− fludarabine) in 36 patients. Fourteen received a bone marrow graft and the remaining 146 received PBSC graft. GVHD prophylaxis consisted of cyclosporine and mycophenolate +/− short course of methotrexate. CMV reactivation was monitored by shell vial blood culture (BC) twice a week from d21 until d100 or longer if clinically indicated. Additional monitoring with quantitative PCR was available in 57 patients. Preemptive therapy with ganciclovir was started at the first positive BC at 5mg/kg twice a day for a week, followed by maintenance therapy for 5 weeks. Of 160 patients, at the time of analysis 94 patients are alive with a median follow up of 12.2 months. The actuarial probabilities of overall survival, disease-free survival, and relapse for the entire cohort at 1 year were 55.9 %, (95%CI: 51.1–60.5), 40.4% (95% CI: 37.1–43.7), and 40.1% (95%CI: 34.8–46.2), respectively. Grade 2–4 acute GVHD occurred in 91 (56%) patients. Eighty-one patients developed CMV reactivation (actuarial probability of 52+/−4%) at the median of 44 days post-transplant (range: d20-d216, 8 after d100). Of these, 42 (52%) had either persistent or recurrent reactivation. Nineteen patients (12%) developed CMV disease (8 with pneumonitis, 11 with GI tract) at the median onset of 56 days (range d28-d591: 5 after d100). Seven of these 19 patients had both BC and PCR data, which were consistent each other in all but one. CMV viremia itself did not predict poorer survival (p=NS), but CMV disease was associated with lower overall survival (37% vs. 65%, p=0.02). The univariate analysis revealed two major findings: 1) CMV seropositive patients were at seven times the ‘hazard' (HR: 7.2, 95%CI: 2.3–22.9) for CMV reactivation compared to those who were CMV seronegative (p<0.001); and 2) patients who received a true non-myeloablative regimen were at decreased ‘risk' for CMV reactivation compared to those who received fludarabine + melphalan or busulfan (HR: 0.42, 95%CI: 0.2–0.8) (p<0.01). In multivariate analysis these factors remained significant.In summary, our data demonstrate the significant incidence of CMV reactivation and disease in RIT, but true non-myeloablative transplants may have lower risk. Future immunologic or pharmacologic interventions should include RIT patients.

POSTTRANSPLANT LYMPHOPROLIFERATIVE DISORDER IN PRIMARY KIDNEY TRANSPLANT RECIPIENTS WITH EPSTEIN-BARR VIRUS NEGATIVE OR POSITIVE SEROSTATUS

P846 Aims: This study was conducted to explore the relationship between Epstein Barr Virus (EBV) serostatus, immunosuppression for induction and discharge maintenance therapies, and other factors on the risk of posttransplant lymphoproliferative disorder (PTLD) development within 400 days after primary deceased or living donor kidney transplants. Methods: The study included over 15,000 primary kidney transplant recipients from the UNOS/OPTN database during 4/1/99-12/31/02, whose pre-transplant EBV serostatus was either positive or negative. Patients were categorized into one of the following induction groups: monoclonal anti-lymphocyte (muromomab-CD3), polyclonal anti-lymphocyte (Anti-thymocyte globulin, thymoglobulin), IL-2 receptor (basiliximab, daclizumab) antibody or no induction. Patients had to be on a discharge maintenance immunosuppression regimen using either cyclosporine (CYA) or tacrolimus (TAC) with azathioprine (AZA) or mycophenolate mofetil (MMF). The analysis also included patient age group, ethnicity (white vs. other), previous malignancy, pre-transplant CMV serostatus, treatment for early acute rejection, and donor type. Multivariate Cox regression models were used to assess the impact of these factors on PTLD by pre-transplant EBV serostatus. Results of the Cox models are presented as relative risk (RR) of PTLD and p-value. Results: The actual incidence of PTLD within 400 days of transplant was 1.05% in EBV seronegative patients and 0.15% in EBV seropositive patients. The table shows the adjusted RR of PTLD for age, CMV serostatus and immunosuppression agents.FigureNote: *MMF effect could not be estimated due to no PTLD events in the AZA group. Conclusions: Younger age was the strongest risk factor for PTLD in EBV negative patients. PTLD in these patients may be related to either transmission of EBV by an EBV positive donor or primary posttransplant EBV infection. In EBV positive patients, CMV seronegativity was strongly associated with an increased risk of PTLD. None of the induction maintenance immunosuppression therapies were associated with a statistically significantly increased risk of PTLD in EBV seronegative patients. In EBV seropositive patients, anti-lymphocyte induction was associated with a marginally increased risk of PTLD. In EBV seronegative patients, TAC was associated with an increased risk of PTLD while MMF was associated with a reduced risk of PTLD. Risk factors for PTLD appeared to differ significantly in EBV seronegative vs. seropositive patients. These data and multiple prior observations confirm the importance of determining pre-transplant EBV serostatus in the donor and recipient.

Acute cytomegalovirus infections in blood donors are indicated by increased serum neopterin concentrations.

In Austria serum neopterin measurement was introduced as an additional unspecific screening marker for the detection of routinely unscreened viral infections in blood donations in 1994. This study was performed to test for associations between serum neopterin concentrations in blood donations and cytomegalovirus infections of the donors. All consecutive blood donations from volunteer blood donors collected during 1 year were incorporated into the study. Serum neopterin concentrations were measured by enzyme-linked immunosorbent assay (ELISA), and each donation of donors with CMV seronegativity or unknown CMV status was also screened for CMV antibodies by CMV IgG/IgM antibody ELISA. Data of donors who had two or more donations within this period were retrospectively analyzed for CMV seroconversions. CMV seroconversion was defined as a change in the donor's CMV status from antibody negative to positive. Frozen, stored plasma samples of the matching donors were tested for CMV IgM antibodies to confirm seroconversion. CMV seroconversions were classified by antibody patterns. In total, 56,068 consecutive blood donations were given by 44,427 volunteer donors. Among these, 9,105 had more than one donation during the observation period, and 4,329 (47.5%) out of these repeated donors were initially CMV antibody negative, of whom 36 were recruited as candidates for CMV seroconversion; 20 conversions were confirmed. All early infections ( n=8) were associated with neopterin concentrations of more than 13 nmol/l (98th percentile of all donations = 12.1 nmol/l) and all donations were excluded from transfusion solely on the basis of their elevated neopterin level. In addition, 17% of late and carrier states ( n=12) showed elevated neopterin concentrations. Acute CMV infections among blood donors presented with elevated serum neopterin concentrations even before CMV IgG/IgM antibodies were detectable.

The risk of transfusion-acquired CMV infection in seronegative solid-organ transplant recipients receiving non-WBC-reduced blood components not screened for CMV antibody (1984 to 1996): experience at a single Canadian center.

The use of CMV-safe cellular blood components has been recommended for CMV-sero- negative recipients of CMV seronegative (R-D-) solid- organ transplants. The incidence of CMV infection in 281 CMV-seronegative patients receiving renal, heart, heart-lung, lung, and liver transplants at our center between January 1984 and October 1996 was studied. The blood components that these patients received were neither WBC reduced nor screened for CMV antibody. One hundred thirty-one of 154 (85.1%) patients receiving organs from CMV-seropositive donors (R-D+) developed CMV infection compared with three cases of presumptive transfusion-acquired (TA) CMV infection in 127 R-D- recipients (2.4%) (relative risk, 36.0; 95% CI, 11.8-110.4). The organ-specific incidence of TA CMV infection in R-D- patients was as follows: renal, 0 of 57 (0%); heart, 0 of 29 (0%); heart-lung and/or lung, 1 of 6 (16.7%); and liver, 2 of 20 (10%). There was no significant difference in the transfusion requirements of CMV-infected and -uninfected R-D- patients. False-positive results were often (40%) observed when posttransfusion serum samples were used for determination of the organ donor CMV serostatus. The low risk of TA CMV infection observed in transplant patients who received standard blood components in our study should be considered when evaluating the efficacy of programs that provide CMV-safe blood components for this population.

Diagnosis of Cytomegalovirus Infections Using Polymerase Chain Reaction, Virus Isolation and Serology

The nested Polymerase Chain Reaction (PCR) was compared with virus isolation and serology to establish which is the best method for the diagnosis of active cytomegalovirus, (CMV) infection. Samples of blood leucocytes, urine and throat washings from immunosuppressed patients and patients with congenitally acquired CMV infection, as well as from healthy persons, were examined with PCR. CMV DNA was detected in all samples from which CMV could be isolated, but not from any sample from healthy adults, whether CMV seropositive or CMV seronegative. In contrast to the findings in healthy persons, CMV genomes were frequently detected in urine and throat washings from immunosuppressed, CMV-seropositive patients without symptoms of CMV infection. The appearance of CMV genomes in blood cells in immunosuppressed CMV-seronegative patients may be the first sign of primary CMV infection. Congenital CMV infection could be rapidly and safely diagnosed when urine samples were examined by PCR. Nested PCR is a valuable tool for the diagnosis of active CMV infection, when selected materials are used.