Erythropoiesis-stimulating agents significantly delay the onset of a regular transfusion need in nontransfused patients with lower-risk myelodysplastic syndrome.

BACKGROUND: The EUMDS registry is an unique prospective, longitudinal observational registry enrolling newly diagnosed patients with lower-risk myelodysplastic syndrome (MDS) from 17 European countries from both university hospitals and smaller regional hospitals. OBJECTIVE: The aim of this study was to describe the usage and clinical impact of erythropoiesis-stimulating agents (ESAs) in 1696 patients enrolled between 2008 and 2014. METHODS: The effects of ESAs on outcomes were assessed using proportional hazards models weighting observations by propensity to receive ESA treatment within a subset of anaemic patients with or without a regular transfusion need. RESULTS: ESA treatment (median duration of 27.5 months, range 0-77 months) was administered to 773 patients (45.6%). Outcomes were assessed in 897 patients (484 ESA treated and 413 untreated). ESA treatment was associated with a nonsignificant survival benefit (HR 0.82, 95% CI: 0.65-1.04, P = 0.09); this benefit was larger amongst patients without prior transfusions (P = 0.07). Amongst 539 patients for whom response to ESA treatment could be defined, median time to first post-ESA treatment transfusion was 6.1 months (IQR: 4.3-15.9 months) in those transfused before ESA treatment compared to 23.3 months (IQR: 7.0-47.8 months) in patients without prior transfusions (HR 2.4, 95% CI: 1.7-3.3, P < 0.0001). Responding patients had a better prognosis in terms of a lower risk of death (HR 0.65, 95% CI: 0.45-0.893, P = 0.018), whereas there was no significant effect on the risk of progression to acute myeloid leukaemia (HR 0.71, 95% CI: 0.39-1.29, P = 0.27). CONCLUSION: Appropriate use of ESAs can significantly delay the onset of a regular transfusion need in patients with lower-risk MDS.

Bacteraemia coincides with low citrulline concentrations after high-dose melphalan in autologous HSCT recipients.

Mucosal damage to the intestines induced by myeloablative conditioning for allogeneic PBSC transplant (PBSCT) can be determined by the concentration of citrulline, which is a functional marker of small intestinal enterocytes. Low citrulline concentrations in blood coincide with and are a response to severe mucosal barrier injury. We treated 29 patients with high-dose melphalan 200 mg/m(2) (Mel-200) to prepare for an autologous PBSCT and collected plasma samples from each patient starting before the myeloablative regimen and three times per week thereafter until discharge. The baseline citrulline concentration was 27.6 mM+/-4.0 (mean+/-95% confidence interval; CI), and citrulline concentrations declined rapidly thereafter reaching a nadir averaging 6.7 mM+/-2.7, 12 days after starting Mel-200. Citrulline concentrations, only increased gradually and were still low (12 mM+/-4) at discharge. A total of 20 patients developed fever, which was associated with bacteraemia in 10 cases. Their mean citrulline concentrations were lower at 5.5 mM+/-1.5 than were those of patients without bacteraemia (10.2 mM+/-3.9). Importantly, neither the number of preceding neutropenic days nor the mean C-reactive protein (CRP) concentration at the onset of fever was different between these two groups. In conclusion, citrulline concentrations rapidly decline after Mel-200 reflecting intestinal mucosal barrier injury. Low citrulline, rather than the duration of neutropenia, is associated with bacteraemia indicating the importance of an intact mucosal barrier in neutropenic patients.

Role of curcumin and the inhibition of NF-kappaB in the onset of chemotherapy-induced mucosal barrier injury.

The inhibition of nuclear factor kappa B (NF-kappaB) by, for instance, curcumin is becoming an important new approach in combination with chemotherapy or irradiation for the treatment of a variety of cancers including haematological malignancies. A dose-limiting side effect of anticancer therapy in the gastrointestinal tract is mucosal barrier injury. It is hypothesised that mucosal barrier injury is initiated and amplified by proinflammatory-and NF-kappaB-regulated mediators. Therefore, the effect of NF-kappaB inhibition was studied in the onset of mucosal barrier injury. In response to cytostatic drug treatment (arabinoside cytosine (Ara-C) and methotrexate (MTX)), NF-kappaB was activated in intestinal epithelial cells (IEC-6) resulting in an NF-kappaB-related induction of tumour necrosis factor alpha and monocyte chemoattractant protein-1. NF-kappaB inhibition increased the susceptibility of IEC-6 cells to Ara-C as well as MTX-induced cell death when obtained by the addition of caffeic acid phenethyl ester (CAPE), but not using curcumin. In an animal model for MTX-induced mucosal barrier injury, the induction of NF-kappaB-related cytokines and chemokines was detected upon treatment with MTX. Despite increased susceptibility shown in vitro, the inhibition of NF-kappaB resulted in a partial amelioration of villous atrophy normally seen in the small intestine upon MTX treatment. These results show that the inhibition of NF-kappaB does not increase intestinal side effects of the anticancer treatment, suggesting a safe use of curcumin and CAPE in combination with anticancer treatment.

Cytotoxic T-lymphocyte precursor frequency (CTLp-f) as a tool for distinguishing permissible from non-permissible class I mismatches in T-cell-depleted allogeneic bone marrow transplantation.

Matching for HLA has been the gold standard in bone marrow donor selection. But, with the ever increasing number of identified HLA alleles, it is becoming more difficult to find a fully HLA-identical donor other than a sibling. Retrospective analysis revealed that HLA mismatches do not necessarily give rise to acute graft-versus-host-disease (GVHD). However, we have no means of defining these 'permissible' mismatches before bone marrow transplantation (BMT). Thus, we set out to establish whether functional matching by means of helper and cytotoxic T-lymphocyte precursor frequency analysis (HTLp-f and CTLp-f respectively) can be applied to this end. Fifty-five recipient-donor pairs other than HLA-identical siblings, the recipient of which received a T-cell-depleted graft, were analysed by high-resolution HLA typing and/or HTLp-f/CTLp-f analysis. The predictive value of the CTLp-f assay for development of acute GVHD was confirmed. More importantly, our data indicate that the CTLp-f assay was able to discriminate permissible from non-permissible HLA-A, -B or -Cw mismatches, but not for DRB/DQB mismatches. The absolute number of alloreactive CTLs present in the graft correlated with the risk of acute GVHD. Although HTLp-f and CTLp-f together had a high negative predictive value, HTLp-f outcome by itself was not correlated with acute GVHD. As we have no evidence yet that HTLp-f or CTLp-f can identify permissible DRB/DQB mismatches, high-resolution matching for these antigens remains the best option. The combination of high-resolution DRB/DQB typing and the CTLp-f assay would enable the accurate prediction of the risk of acute GVHD while extending the pool of potential donors. Furthermore, it would enable adjustment of the number of T- cells in the graft accordingly to improve clinical outcome.

A retrospective Dutch study comparing T cell-depleted allogeneic blood stem cell transplantation vs T cell-depleted allogeneic bone marrow transplantation.

Retrospectively, a cohort of 43 hematological patients receiving an allogeneic T cell-depleted (TCD)-PBSCT between 1994 and 1997, was compared to a cohort of 435 patients, who received an allogeneic TCD-BMT between 1990 and 1996. Both cohorts were comparable with respect to diagnosis, risk status, age and sex. PB grafts contained four to five times more hematopoietic progenitor cells and T cells as compared to BM grafts. T cell depletion was performed by either elutriation, CD34 selection, E-rosetting, or Campath serotherapy. Conditioning was cyclophosphamide/TBI in the majority of patients of both cohorts. All patients received cyclosporin A as GVHD prophylaxis until day 90 post-transplant. Engraftment was significantly faster in the PBPCT cohort with a median time to neutrophil recovery (>0.5 x 10(9)/l) of 16 vs 21 days in the BMT cohort (P = 0.0009). Platelet recovery to 50 x 10(9)/l was 16 vs 34 days for the PB and BM cohort respectively (P < 0.0001). A median percentage of 76% of BMT patients recovered to 50 within 100 days post-BMT vs 91% of patients receiving a PB graft. The incidence of acute GVHD grades II, III and IV was similar in both cohorts. In contrast, the probability of developing chronic GVHD was 21% in the BM cohort vs 37% in the PB cohort. Relapse incidence was reduced in the PB cohort (9 vs 29%), while treatment-related mortality was not different for both cohorts. These favorable results require confirmation by a prospective randomized trial, which is currently being performed by several European centers.

The low cycling status of mobilized peripheral blood CD34+ cells is not restricted to the more primitive subfraction.

Mobilized peripheral blood progenitor cells (PBPC) have been shown to differ qualitatively from bone marrow (BM) progenitors. The released progenitor cells are predominantly in G0/G1 and show a relatively high percentage of rhodamine dull cells. Within the BM these last two features are characteristic of the more primitive progenitors. Although the mobilized PB cells can give rise to long-term repopulation and thus contain stem cells, the frequency of stem cells is not much higher if long-term initiating cell (LTC-IC) assays are used. To determine whether quiescent stem cells are selectively released or the low-cycle status of PB progenitors is related to the release from the BM microenvironment, the cell cycle status and rhodamine content in the PB and BM during mobilization were studied and compared with steady-state BM. More differentiated and more primitive progenitors were separated based on differentiation markers and cloned in single cell assay. In mobilized PB 54% of the CD34+ cells (n=5) were rhodamine dull compared to 22% in steady-state BM (P=0.014) [n=6]. The percentage of CD34+ cells in the S/G2M phases of the cell cycle was 2.1% in the mobilized PB (n=11), and 18% in steady-state BM (n=11) [P=0.002]. During mobilization the fraction of cells in the S/G2M phase of the cell cycle was 16% in BM (n=7), similar to steady-state BM (P=0.34). The released progenitors represented a selection of BM progenitors, with significantly more primitive progenitors (CD34+/13+/33dim) and less lymphoid precursors (CD34+/19+). Within the more differentiated CD34+113+/33bright, myelomonocytic precursors, both in PB as well as in BM, the percentage S/G2M was relatively higher than in the CD34+/13+/33dim subfraction: in normal BM: median 18% vs 8% (P=0.006) [n=8]; in mobilized PB 3% vs 2% (P=0.03) [n=10]; and in BM during mobilization 24% vs 7% (P=0.01) [n=6]. The cycle status of mobilized PB progenitors was low both in the primitive and more differentiated subfractions. During the mobilization period the BM progenitors are cycling as in steady-state BM. The low-cycle status of the mobilized PB progenitors may be related to the loss of contact with the micro-environment.

The role of the different CD34 epitopes in detection and positive selection of CD34+ bone marrow and peripheral blood stem cells.

Positive selection of CD34+ cells is an attractive approach to reduce tumour cell contamination in bone marrow (BM) and peripheral blood progenitor cell (PBPC) autografts in malignancies not expressing CD34. All current selection methods use monoclonal antibodies (MoAbs) specific for the class I or class II CD34 epitopes, while for detection most investigators use class III MoAbs. Since the distribution of the different CD34 epitopes on haematopoietic progenitors differs, we studied their significance in CD34+ selection procedures. Testing MoAbs against class I, II and III CD34 epitopes on normal BM we observed that +/- 23% of class III positive cells was class I negative. A higher expression of the class III epitope compared with classes I or II was observed on the KG1 cell line, whereas no differences in binding capability were found. The class III epitope anti-CD34, 561, was compared with the class I epitope anti-CD34, BI-3C5, both coupled to M450 Dynabeads. The yield of CD34+ cells obtained with the 561 beads was 1.7% of the mononuclear cells versus 0.95% using the class I epitope, a 1.95-fold increase (1.3-2.7), whereas the purity was similar (96% in both cases). The absolute number of CD34+ cells was therefore twofold higher after 561 selection, including cells with a more mature phenotype. In single cell assay comparable numbers of highly proliferative progenitors but higher numbers of differentiated colonies per phenotypic subfraction were measured. In conclusion, M450 beads coated with the 561 anti-class III CD34 epitope are more efficient in isolating CD34+ cells from bone marrow, probably due to a broader distribution of the class III epitope.

Helper and cytotoxic T cell precursor frequencies are not predictive for development of acute graft-versus-host disease after partially T cell-depleted HLA-identical sibling BMT.

Despite the use of partially T cell-depleted grafts, 20% of the recipients of an HLA-identical sibling marrow graft develop aGVHD > or = II. This indicates that the current method for selecting a sibling donor, ie serological typing for HLA-A, B and DR, and a mixed lymphocyte culture (MLC) or molecular typing for HLA-DRB/DQB, is not predictive for aGVHD. In order to optimise our selection procedure, we retrospectively analysed patients who developed aGVHD > or = II by means of sequencing based typing for HLA-DPB and frequency analysis of alloreactive helper and cytotoxic T lymphocyte precursors (HTLp-f and CTLp-f). Patients who did not develop aGVHD or developed aGVHD grade I served as controls. Retrospective typing for HLA-DPB revealed only a single disparity in the group with aGVHD > or = II, indicating that mismatches for antigens other than HLA are the major cause of aGVHD in these patients. Furthermore, in our patient group, neither HTLp-f nor CTLp-f were predictive for development of aGVHD indicating that these assays in their current set-up are insufficiently sensitive to predict aGVHD in BMT with a partially T cell-depleted graft. We conclude, that HLA-identical siblings can be identified by means of serological typing for HLA-A and B and intermediate resolution molecular typing for DRB and DQB, but that for the prediction of aGVHD cellular tests with higher sensitivity and specificity as compared to the currently used HTLp-f and CTLp-f assays need to be developed.

[The success of lymphocyte infusion as treatment of leukemia recurrence following allogeneic bone marrow transplantation depends on low percentage of patient's own lymphocytes]. / Succes van infusie met lymfocyten als behandeling van leukemierecidief na allogene beenmergtransplantatie is afhankelijk van een laag percentage eigen lymfocyten.

OBJECTIVE: Evaluation of induction of complete remission with infusion of lymphocytes from the original bone marrow donor in patients with leukaemia which relapsed after allogeneic bone marrow transplantation. SETTING: Division of Haematology, University Hospital Nijmegen and the Red Cross Blood Bank Nijmegen, the Netherlands. DESIGN: Prospective, non-randomized study. METHODS: Twenty-eight patients who relapsed after allogeneic bone marrow transplantation were treated with infusion of lymphocytes from the original bone marrow donor. Lymphocytes were collected by means of leukapheresis. Follow-up was done by frequent checks at the outpatient clinic. RESULTS: Eleven of 15 (73%) patients with relapsed chronic myeloid leukaemia (CML) and only one of 13 patients (8%) with a relapse of acute leukaemia went into complete remission (p < 0.001). Entering complete remission was always preceded by acute or chronic graft-versus-host disease (GVHD). The development of acute and/or chronic GVHD was significantly associated with the origin of T-lymphocytes in the blood of the recipient at the time of infusion. If the T-lymphocytes came mostly from the patient himself, the infusion remained usually without effect. If the T-lymphocytes came mostly from the donor, the patients went into complete remission. CONCLUSION: Patients with a relapse of leukaemia after allogeneic bone marrow transplantation may enter complete remission after infusion of lymphocytes from the original marrow donor. This form of immunotherapy can be successful especially in patients with a relapsed CML with a relatively low percentage of autologous T-lymphocytes at the time of infusion.

Randomized placebo-controlled trial of granulocyte-macrophage colony-stimulating factor in patients with chemotherapy-related febrile neutropenia.

PURPOSE: To determine whether granulocyte-macrophage colony-stimulating factor (GM-CSF) used in addition to standard inpatient antibiotic therapy shortens the period of hospitalization due to chemotherapy-induced neutropenic fever. PATIENTS AND METHODS: One hundred thirty-four patients with a hematologic (n = 47) or solid tumor (n = 87) who had severe neutropenia (< 0.5 x 10(9)/L) and fever (> 38.5 degrees C once or > 38 degrees C twice over a 12-hour observation period) were randomly assigned to receive GM-CSF 5 micrograms/kg/d (n = 65) or placebo (n = 69) in conjunction with broad-spectrum antibiotics for a minimum of 4 days and a maximum of 14 days. GM-CSF/placebo and antibiotics were stopped if the neutrophil count was greater than 1.0 x 10(9)/L and temperature less than 37.5 degrees C during 2 consecutive days, or for a leukocyte count > or = 10 x 10(9)/L, both followed by a 24-hour observation period (hospitalization period). RESULTS: Compared with placebo, GM-CSF enhanced neutrophil recovery. Median neutrophil counts at day 4 were 2.5 x 10(9)/L (range, 0 to 25) in the GM-CSF arm and 1.3 x 10(9)/L (range, 0 to 9) in the placebo arm (P < .001). No significant difference was observed with regard to median number of days with less than 1.0 x 10(9)/L neutrophils (4 v 4) or days of fever (3 v 3). The median number of days patients were hospitalized while on study was comparable in the GM-CSF and placebo groups at 6 (range, 3 to 14) versus 7 (range, 4 to 14), respectively, according to an intention-to-treat analysis (P = .27). Quality-of-life scores in 90 patients demonstrated significant differences in favor of the placebo group. Hospital costs were significantly higher for GM-CSF-treated patients if GM-CSF was included in the price (median costs, $4,140 [US] for GM-CSF v $590 for placebo; P < .05). CONCLUSION: These results indicate that GM-CSF does not affect the number of days for resolution of fever or the hospitalization period for this patient group, although a significant effect of GM-CSF was observed on neutrophil recovery.

Cell cycle kinetics of hematopoiesis before and after in vivo administration of GM-CSF in refractory anemia: evidence for a shortening of the granulocyte release time.

GM-CSF administration to patients with refractory anemia (RA) induces an increase in neutrophils and eosinophils. We studied cell kinetic mechanisms underlying this observation using clonogenic assays and in vivo iododeoxyuridine labeling of bone marrow cells. Cell cycle kinetics were studied in three patients before and during GM-CSF administration (two daily subcutaneous injections of 54 or 108 micrograms). No consistent effect on the relative number of bone marrow CFU-GM was noticed. The DNA synthesis time and potential doubling time of low-density bone marrow cells remained essentially the same. A slight decrease (1.5-3.7%) in labeling index was found, originating from the myelo(-mono)cytic lineage. In all three patients the release time of labeled granulocytes from the bone marrow into the peripheral blood was shortened (before GM-CSF treatment 5-7 days and during GM-CSF 3-4 days). Cell cycle kinetics of CD34+ cells were studied in order to obtain kinetic information on immature precursor and progenitor cells. The DNA synthesis time of the CD34+ cells was shortened during GM-CSF therapy, resulting in a shorter potential doubling time. GM-CSF administration to patients with RA results in a rise in granulocytes that might be due partly to an accelerated release of granulocytes from the bone marrow compartment into the circulating blood and partly to an increased proliferative activity of the immature precursor and progenitor cells.

Peripheral blood cell harvests yield primitive multilineage progenitor cells in the CD34+/33- fraction.

The presence of primitive hematopoietic progenitor cells or stem cells in peripheral blood (PBSC's) harvests was investigated in a single cell culturing assay and compared with the results obtained in aspirates of normal bone marrow. Based on the presence of CD33, rather differentiated progenitor cells (CD34+/33+) were distinguished from more primitive cells (CD34+/33-). The growth potential of CD34+/33+ and CD34+/33- cells have been studied. Single cell sorting was performed from peripheral blood harvests, obtained from three patients with multiple myeloma during hematopoietic recovery after treatment with high dose cyclophosphamide and rhu-GM-CSF. To test the effect of "stem cell recruiting factors" the cells were sorted in 96-well plates, prefilled with liquid medium both in the presence of IL-3 + G-CSF+GM-CSF+Epo and the same growth factors supplemented with SCF+IL-6. Addition of SCF and IL-6 to the culturing medium enhanced the plating efficiency of CD34+/33- cells considerably more than that of CD34+/33+ cells. This was observed in harvests of peripheral blood as well as in aspirates of normal bone marrow. The differences between CD34+/33+ and CD34+/33- were even more pronounced when only the large colonies (> 500 cells/well) were taken into consideration. Assuming that IL-6 and SCF are "stem cell recruiting factors," the CD34+/33- fraction contains more clonogenic cells than the CD34+/33+ fraction. In all three patients the first CD34+ cells appearing in the peripheral blood (PB) after cytoreductive treatment were predominantly CD34+/33- (> 80%). At later stages when the leukocyte counts had reached higher values the CD34+/33+ cells predominated.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunological detection of cytomegalovirus early antigen on monolayers inoculated with urine specimens by centrifugation and cultured for 6 days as alternative to conventional virus isolation.

Detection methods for human cytomegalovirus were evaluated with 431 urine samples from 30 bone marrow and 88 kidney transplant recipients. Low-speed centrifugal inoculation was followed by early antigen (EA) detection by means of indirect immunofluorescence with a monoclonal antibody after 1 (EA-1) and 6 (EA-6) days of cultivation. The results were compared with those of conventional virus isolation (CVI). Of 68 positive samples, 49 (72%) were detected with EA-1, 58 (85%) were detected with EA-6, and 43 (63%) were detected with CVI. The combination of EA-1 and EA-6 showed positive results with 66 samples (97%), which is significantly better than with CVI (P less than 0.001). With the exception of one patient, all CVI-negative but EA-positive samples had either significant rises in immunoglobulin G (IgG) or IgA antibody titer or IgM antibodies present in the sera. These data indicate that the method with EA detection can replace CVI, provided that each sample is inoculated in duplicate. Sample 1 is examined after 1 day, and if it is negative, sample 2 is incubated for a further 5 days, followed by detection of cytomegalovirus.

In vivo cellular adriamycin concentrations related to growth inhibition of normal and leukemic human bone marrow cells.

Inhibition of clonogenicity of normal and leukemic human hematopoietic progenitor cells was studied after in vivo and in vitro exposure of bone marrow to adriamycin (ADM). Flow cytometric determination of cellular ADM concentrations in blast cells, expressed in fluorescence units/cell (FU/cell), correlated well with the extent of cytotoxicity. After 2 h in vitro exposure to 500 ng ADM/ml, the ADM concentration of leukemic (n = 7) and normal (n = 4) bone marrow blast cells amounted to 231 +/- 180 and 249 +/- 53 FU/cell respectively, producing moderate decreases in clonogenicity by 44 +/- 30 and 54 +/- 27%. Exposure to 2000 ng/ml produced ADM concentrations of 1184 +/- 472 FU/cell for leukemic blast cells and 1024 +/- 281 FU/cell for normal blast cells. Inhibition of clonogenicity was 96 +/- 7% in leukemic blasts and 99 +/- 1% in normal blasts. In vivo ADM concentrations in leukemic blast cells at 1-2 h after administration were 216 +/- 98 FU/cell (n = 8 patients). This implies that inhibition of clonogenicity after administration of conventional dosages of ADM will be approx. 60-70% for both leukemic and normal bone marrow progenitor cells. Such values were noted in four patients of whom bone marrow was cultured, which was obtained shortly after ADM monotherapy.

Erythrocyte repopulation after allogeneic bone marrow transplantation. Analysis using erythrocyte antigens.

Blood samples from 31 of 50 consecutive patients receiving bone marrow from an HLA-identical and mixed lymphocyte culture-nonreactive sibling were investigated for the presence of donor and autologous erythrocytes. Simple serological techniques using antigenic differences between donor and recipient and a blood transfusion policy taking these differences into account made this study possible. A total of 71% of the patients had donor erythrocytes demonstrable 4 weeks after bone marrow transplantation; almost all patients did so after 2 months. Disappearance or absence of donor red cells indicated poor patient prognosis. Persistence or reappearance of autologous erythrocytes in small percentages (0.05-10%) occurred without relapse of leukemia. Reappearance in high percentage (50-100%) indicated relapse.

Effect of cytomegalovirus infection on T-lymphocytes after lymphocyte-depleted bone marrow transplantation.

The effect of cytomegalovirus (CMV) infection on the repopulation of the peripheral blood with T-lymphocytes was studied in recipients of lymphocyte-depleted bone marrow transplants (BMT) who had hematologic and cytogenetic evidence of engraftment. Lymphocyte depletion was performed using counterflow centrifugation and resulted in a median depletion of 98.4% (range 94.4%-99.8%) of the T cells. Between 8 and 105 days after BMT, the T-cell repopulation was characterized by a relative preponderance of T cells lacking the CD3 marker and a slow repopulation of CD3+, CD4+, and CD8+ T cells. The CD8+ T cells repopulated at a faster rate in patients with CMV infection than in those not infected with CMV. At the end of the 9- to 12-month follow-up period, patients with CMV infection had normal numbers of CD4+ and CD8+ T cells but increased numbers of HNK1+ T cells. Those without CMV infection had subnormal numbers of CD4+ T cells, normal numbers of CD8+ T cells, and numbers of HNK1+ T cells that attained the upper limit of the normal range. Most of the HNK1+ T cells in both patient groups coexpressed the CD8 marker. We conclude that the occurrence of CMV infection in recipients of lymphocyte-depleted BMT is associated with an increase in the number of T cells coexpressing CD8 and HNK1, just as in recipients of nondepleted BMT.