Features of Cytomegalovirus DNAemia Blips in Allogeneic Hematopoietic Stem Cell Transplant Recipients: Implications for Optimization of Preemptive Antiviral Therapy Strategies.

Cytomegalovirus (CMV) DNAemia occurs frequently in allogeneic hematopoietic stem cell transplant recipients (allo-HSCT). There is limited information about the incidence, features, and clinical impact of CMV DNAemia blips (episodes defined by an isolated positive PCR result) in this setting. In this retrospective study, 225 consecutive adult patients undergoing any modality of allo-HSCT at our center between May 2012 and July 2019 were included. Plasma CMV DNA load was monitored using a highly sensitive real-time PCR assay. In all, 187 of 225 patients had CMV DNAemia through day 365 after allo-HSCT (total number of episodes, n = 379). Eighty-three of the 187 patients had 1 or more blips (n = 104). Blips occurred as a first episode of CMV DNAemia as opposed to prolonged CMV DNAemia (≥2 consecutive positive PCR results) in 47 patients; in 20 of these patients, blips represented the only documented episode throughout the study period, and in 27 patients, blips preceded a prolonged CMV DNAemia episode. In the remaining 36 patients, blips developed as recurrences. Blips presenting as initial episodes occurred more frequently (P < .001) in patients receiving an allograft from a CMV-seropositive donor. The cumulative incidence of recurrent CMV DNAemia following initial blips, self-resolving prolonged CMV DNAemia episodes, or CMV DNAemia episodes treated preemptively with antivirals was not significantly different (P = .34). Receiver operating characteristic curve analysis indicated that a CMV DNA load cutoff of 48 IU/mL yielded the highest combined sensitivity (66%) and specificity (70.2%) for predicting a prolonged CMV DNAemia episode. The practical implications of our data in the optimization of preemptive antiviral therapy strategies are discussed.

An investigation of the utility of plasma Cytomegalovirus (CMV) microRNA detection to predict CMV DNAemia in allogeneic hematopoietic stem cell transplant recipients.

Precise identification of patients at highest risk for developing Cytomegalovirus (CMV) DNAemia may improve CMV infection management in the allogeneic hematopoietic stem cell transplantation (allo-HSCT) setting. Here, we studied the potential use of detecting free CMV micro(mi)RNAs circulating in plasma for predicting CMV DNAemia in this clinical scenario. A total of 62 adult allo-HSCT recipients were included in this prospective observational multicenter study. Plasma CMV DNA load was monitored using the CMV RealTime CMV PCR (Abbott Molecular, Des Plaines, IL, USA). Detection of mature CMV miRNAs in plasma drawn by days + 7, + 14 and + 30 after allo-HSCT was performed using the miScript PCR System (Qiagen, Hilden, Germany). Assays could be optimized for five out of the seven targeted CMV miRNAs: UL36-5p, US33-5p, UL148D, UL22A-5p and UL112-3p. Of the 62 patients included in the study, 42 developed a first episode of CMV DNAemia at a median of 35 days after allo-HSCT. All targeted CMV miRNA were detected early after transplantation, with CMV miRNA US33-5p and UL112-3p the most commonly found species at any time point; nevertheless, neither the detection rate of CMV miRNAs nor their abundance allowed discrimination between patients with subsequent CMV DNAemia and those with no CMV DNAemia. The data presented herein do not support any predictive utility of these CMV miRNAs for first episodes of CMV DNAemia in a cohort consisting primarily of allo-HSCT patients receiving haploidentical allografts.

Kinetics of inflammatory biomarkers in plasma predict the occurrence and features of cytomegalovirus DNAemia episodes in allogeneic hematopoietic stem cell transplant recipients.

Cytomegalovirus (CMV) DNAemia occurs frequently in CMV-seropositive allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients, and usually results from reactivation of latent infection established in the recipient. Predicting the occurrence of CMV DNAemia may be helpful in managing CMV infection in allo-HSCT recipients. Here, the kinetics of several inflammatory biomarkers in plasma were characterized and assessed for their potential value in anticipating the development and features of active CMV infection in allo-HSCT recipients, as documented using real-time PCR assays. The cohort consisted of 46 non-consecutive adult patients who underwent T-cell replete allo-HSCT at our center. Plasma levels of C-reactive protein (CRP), soluble tumor necrosis factor receptor type 2 (sTNF-R2), transforming growth factor-ß1 (TGF-ß1), and interferon-inducible protein 10 (IP-10/CXCL10) were measured in consecutive specimens obtained from conditioning either by nephelometry (CRP) or by specific immunoassays (the rest). Of the 46 patients, 22 had a first episode of CMV DNAemia at a median of 34 days after allo-HSCT (range, day 19-day 50). We found that both the TGF-ß1 area under a curve (AUC) and peak levels were significantly lower in patients who subsequently developed CMV DNAemia than in patients with no CMV DNAemia. Interestingly, CRP but not TGF-ß1 AUC and peak levels predicted the occurrence of CMV DNAemia episodes requiring preemptive antiviral therapy. The data presented herein suggest that kinetics of inflammatory biomarkers in plasma might be useful to anticipate post-engraftment CMV DNAemia episodes and predict the need for preemptive antiviral therapy in allo-HSCT recipients.

Spontaneously-resolving episodes of cytomegalovirus DNAemia in allogeneic hematopoietic stem cell transplant recipients: Virological features and clinical outcomes.

It has been reported that low-plasma cytomegalovirus (CMV) DNA loads are associated with an increased risk of overall mortality in allogeneic hematopoietic stem cell transplantation (allo-HSCT). Utilizing a conservative strategy for initiation of preemptive antiviral therapy (>1500 IU/mL), we characterized the virological features of spontaneously-resolving episodes of CMV DNAemia and assessed their impact on mortality through the first year after transplantation. We reviewed the CMV DNA polymerase chain reaction results and clinical charts of 230 consecutive adult patients who underwent T-cell replete allo-HSCT at our center. A total of 280 episodes of CMV DNAemia were registered in 164 patients, of which 144 episodes cleared spontaneously. Clearance of CMV DNAemia was significantly delayed in initial and recurrent self-resolving episodes featuring CMV DNA peak loads > 250 IU/mL compared with those displaying lower values. All-cause mortality in patients with self-resolving episodes of CMV DNAemia was comparable (P = 0.7) to that in patients with no CMV DNAemia and was not related to the CMV DNA peak load (≥250 IU/mL vs <250 IU/mL) (P = 0.6). In summary, in our setting, the magnitude of the CMV DNA peak load reached during self-resolving episodes of CMV DNAemia correlated directly with duration of episodes, but had no apparent impact on all-cause mortality taking patients with no documented CMV DNAemia as a reference.

Validation of a plasma metabolomics model that allows anticipation of the occurrence of cytomegalovirus DNAaemia in allogeneic stem cell transplant recipients.

A plasma metabolomic model obtained by means of untargeted 1H nuclear magnetic resonance, to which taurine, choline, methylamine, total glutathione, trimethylamine N-oxide, lactate, lysine, isoleucine, total fatty acids and unsaturated fatty acids contributed, was validated for the prediction of first episodes of cytomegalovirus (CMV) DNAaemia in a cohort of 79 allogeneic stem haematopoietic stem cell transplant (allo-HSCT) recipients. The predictive success rate was nearly 65 % for patients at both low and high risk of CMV-related complications according to their baseline characteristics. Plasma metabolomics profiling shortly after engraftment (day 21 after transplantation) allowed the anticipation of the occurrence of CMV DNAaemia in 71 % of patients. Plasma metabolomics analyses may be ancillary for identifying allo-HSCT patients at the highest risk of CMV DNAaemia who may benefit from early targeted antiviral prophylaxis.

Kinetics of torque teno virus DNA load in saliva and plasma following allogeneic hematopoietic stem cell transplantation.

Plasma torque teno virus (TTV) DNA load directly correlates with the degree of T-cell immune reconstitution early after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Here, the kinetics of oral TTV DNA shedding was examined to assess whether quantitation of TTV DNA load in saliva may either replace or complement that in plasma for predicting lymphocyte (ALC) reconstitution after engraftment. This prospective observational study enrolled 38 nonconsecutive allo-HSCT recipients. Saliva and plasma specimens were collected at baseline (pretransplant) and at around days +30, +50, and +90 after allo-HSCT. TTV DNA was quantitated in both specimen types by real-time PCR. ALCs were measured by cytometry. A total of 104 paired saliva and plasma specimens were available for TTV PCR analyses. TTV DNA was detected more frequently in saliva than in plasma specimens at all time points (overall, 94.2% vs 86.5%). Increasing levels of TTV DNA were seen in both specimen types from day +30 to day +90 after transplantation. Overall, TTV DNA loads were significantly higher in saliva than in plasma specimens (P = .0002) and correlated significantly (P ≤ .0001). A direct correlation between TTV DNA loads in saliva and plasma and ALCs was observed after engraftment (P = .034 and P = .002, respectively). Future studies should be aimed at determining whether monitoring of oral TTV DNA shedding may be of any utility for inference of immune reconstitution after allo-HSCT.

Monitoring of oral cytomegalovirus DNA shedding for the prediction of viral DNAemia in allogeneic hematopoietic stem cell transplant recipients.

Preemptive antiviral therapy based on detecting cytomegalovirus (CMV) DNAemia above a preestablished threshold is the mainstay strategy for the prevention of CMV disease in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients; nevertheless, CMV DNAemia, even at low levels, may increase mortality. We investigated whether surveillance of saliva for the presence of CMV DNA may anticipate the occurrence of CMV DNAemia. This was a prospective observational study with 53 consecutively enrolled allo-HSCT recipients. Saliva and plasma specimens were collected on a weekly basis from Day 0 to Day 100 after transplantation. CMV DNA was quantified in both specimen types using the Abbott Real-Time PCR assay (Abbott Molecular, Des Plaines, IL). CMV DNA was quantifiable in 44 (83%) patients: either in saliva (n = 1) or plasma (n = 12) only, or in both specimen types (n = 31). CMV oral shedding preceded the occurrence of CMV DNAemia in eight patients (18.2%), while the opposite pattern was observed in 21 patients (47.7%). The CMV DNA loads quantified in saliva and plasma correlated modestly (P = 0.33; P = 0.013) and did not differ in magnitude (P = 0.527). No transplantation factors, other than recipient CMV seropositivity, were associated with oral CMV DNA shedding; serum CMV IgG levels were comparable, regardless of the timing of the detection of CMV DNA at both sites. In summary, screening of saliva specimens for the presence of CMV DNA appear to be of limited value for anticipating the occurrence of CMV DNAemia in allo-HSCT recipients.

Epstein-Barr virus DNA load kinetics analysis in allogeneic hematopoietic stem cell transplant recipients: Is it of any clinical usefulness?

BACKGROUND: There is a lack of clinical information regarding the usefulness of plasma Epstein-Barr virus (EBV) DNA load kinetics analyses in the management of EBV infections in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Namely, it remains unknown whether this type of analysis can help physicians to anticipate the development of high-level EBV DNAemia episodes requiring rituximab treatment or predict the risk of recurrent EBV DNAemia or post-transplant lymphoproliferative disorders (PTLDs). STUDY DESIGN: Unicentric, retrospective, observational study including 142 consecutive patients undergoing T-cell replete allo-HSCT. The plasma EBV DNA load was monitored on a weekly basis using the artus® EBV PCR kit. RESULTS: Fifty-five of the 142 patients (38.7%) developed at least one episode of EBV DNAemia; 13 of the 55 initial EBV DNAemia episodes (23.6%) were preemptively treated with rituximab, 7 patients had a recurrent episode of EBV DNAemia, and biopsy-proven PTLDs were diagnosed in 4 patients. The initial plasma EBV DNA load was not significantly different (P=0.269) in episodes of self-resolving EBV DNAemia, those requiring rituximab treatment, or those leading to PTLDs. The plasma EBV DNA load doubling times were similar across all the groups (P=0.799), and the EBV DNA-load half-life was not associated with the occurrence of recurrent EBV DNAemia (P=0.550). CONCLUSION: Plasma EBV DNA-load kinetics analyses are unlikely to be useful in predicting the occurrence of high-level EBV DNAemia, PTLD, or recurrent EBV DNAemia.

Assessing the risk of cytomegalovirus DNAaemia in allogeneic stem cell transplant recipients by monitoring oxidative-stress markers in plasma.

The level of antioxidants, such as thiol-containing tripeptide glutathione (GSH), in cytomegalovirus (CMV)-infected cells is notably increased. We previously showed that GSH levels in plasma, as measured by untargeted 1H nuclear magnetic resonance, are higher in allogeneic stem cell transplant (allo-SCT) recipients who subsequently develop CMV viraemia. We hypothesized that the net level of oxidative-stress markers present in plasma may be reduced in patients who develop CMV DNAaemia compared to those who do not. We serially monitored the levels of malondialdehyde (MDA) and carbonylated proteins (CPs) early after allo-SCT and assessed whether they could predict the occurrence of CMV DNAaemia. MDA levels were measured in 43 patients (28 had CMV DNAaemia) and CPs were quantified in 53 patients (38 patients developed CMV DNAaemia). The area under the curve (AUC) value for MDA, but not for CPs, was significantly lower in patients who subsequently developed CMV DNAaemia compared to those who remained DNAaemia-free (P=0.043). A trend toward lower MDA AUC values was observed in episodes of CMV DNAaemia with faster CMV replicative kinetics and in those who reached higher peak CMV DNA levels. Moreover, receiver operating characteristic curve analyses indicated that the MDA biomarker had the predictive ability to discriminate between patients with or without subsequent CMV DNAaemia (AUC=0.69, 95 % confidence interval 0.51-0.85, P=0.05). In summary, serial quantitation of MDA may be useful for individualizing antiviral prophylaxis therapies (targeted prophylaxis) in the upcoming era of new antiviral drugs with improved safety profiles.