Risk factors for cytomegalovirus reactivation after CD6+ T-cell-depleted allogeneic bone marrow transplantation

BACKGROUND: Cytomegalovirus (CMV) infection is a significant cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). Recipients of T-cell-depleted (TCD) transplants may be more susceptible to CMV infection as a result of the reduction in transferred T cell immunity. We sought to determine the effect of prior donor and patient CMV exposure on the incidence of CMV infection after TCD allogeneic HSCT. METHODS: We retrospectively examined CMV antigen testing results in all patients who had undergone CD6+ TCD related and unrelated donor allogeneic HSCT at our institution from 1996 to 1999. All 124 patients who had documented donor and recipient CMV serologies pretransplant and had undergone CMV antigen testing before day +100 posttransplant were included in the analysis. RESULTS: Forty-one percent of seropositive recipients and 1% of seronegative recipients developed evidence of CMV reactivation (odds ratio 54.1, 95% confidence interval [CI] 6.9-424.1, P<0.001). Prior donor CMV exposure did not place seronegative recipients at increased risk of CMV conversion. Multivariable analysis indicated that prior donor CMV exposure significantly reduced the risk of CMV reactivation in seropositive recipients by 81% (odds ratio 0.19, 95% CI 0.04-0.91, P=0.04). Grades II to IV acute graft-versus-host disease (GVHD) was associated with CMV conversion (P=0.04) when seropositive recipients underwent HSCT from CMV-negative donors, but not when the donor was CMV-seropositive (P=0.54). CONCLUSIONS: The CMV serology status of the recipient, rather than the donor, was the primary determinant of risk for CMV conversion after TCD allogeneic HSCT. Despite CD6+ T-cell depletion, immunity against CMV seemed to be transferred with the donor graft and protected seropositive HSCT recipients from CMV reactivation.     

低剂量膦甲酸钠治疗骨髓移植后巨细胞病毒感染

目的 探讨采用低剂量膦甲酸钠治疗HLA单倍型相合骨髓移植后巨细胞病毒(CMV)感染的临床效果及不良反应.方法 行HLA单倍型相合未去T淋巴细胞骨髓移植的患者54例,移植前采集供、受者外周血,采用CMV Brite试剂盒检测CMV磷蛋白(CMV pp65)阳性细胞.受者于移植前9 d开始采用更昔洛韦预防CMV感染,至移植当天改为阿昔洛韦.患者的造血功能恢复后,每周检测CMV pp65,阳性者即给予膦甲酸钠60 mg·kg-1·d-1,至CMV pp65转为阴性3 d后停药.结果 54例均获得造血功能重建,其中18例移植后CMV pp65为阳性,发生时间为移植后30～93d,应用膦甲酸钠治疗7～21 d后全部转阴,其中1例考虑为CMV肠炎,将膦甲酸钠的剂量增加至120 mg·kg-1·d-1.膦甲酸钠治疗前后,患者的血电解质、肾功能、白细胞和血小板数等均无明显变化.结论 低剂量膦甲酸钠能有效控制骨髓移植后CMV感染,且无严重不良反应.     

Faster immunological recovery after bone marrow transplantation in patients without cytomegalovirus infection

The following findings were noted among 45 bone marrow transplant recipients. The patients without cytomegalovirus (CMV) infection or chronic graft-versus-host disease (GVHD) showed normal lymphocyte stimulation in vitro by concanavalin A (Con A) more than 3 months after transplantation, and normal stimulation by phytohemagglutinin (PHA), anti-beta 2-microglobulin (A-beta 2m) and protein A (SpA) after 6 months. In contrast, the patients who had CMV infection without chronic GVHD had Con A and SpA responses within the normal range after 12 months and reduced lymphocyte responses to PHA and A-beta 2m more than 12 months after transplantation. The patients with chronic GVHD had reduced responses to all of these four mitogens after more than 12 months. In comparison with other patients those who later developed chronic GVHD showed an increased mixed lymphocyte culture stimulation during the first 3 months that decreased between 6-12 months. Patients with chronic GVHD still had reduced IgA levels at 12 months after transplantation. Patients with CMV infection, but without chronic GVHD, had higher percentages of lymphocytes with surface membrane Ig than healthy controls during the first 3 months after transplantation. The data suggest that CMV infection, regardless of chronic GVHD, delays immunologic recovery after marrow transplantation.     

Bone marrow repopulation capacity after transplantation of lymphocyte-depleted allogeneic bone marrow using counterflow centrifugation

Bone marrow from six allogeneic HLA-matched and MCL nonreactive siblings was fractionated by means of isopycnic flotation centrifugation and subsequent counterflow centrifugation. The low density fraction (d less than or equal to 1.070 g/ml) obtained by IFC contained 20% of the nucleated cells and more than 90% of the myeloid and erythroid progenitors. The putative stem cell fraction obtained by CC showed a satisfactory recovery (88%) of the CFU-GM and BFU-E and only 3.5% of the original number of T lymphocytes. Bone marrow repopulation capacity was not impaired in comparison with a comparable group of patients. Despite the average high age of this group (29.6 years), only one of the four evaluable patients developed graft-versus-host disease.     

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.     

肝移植术后巨细胞病毒感染的防治

目的: 探讨肝移植术后巨细胞(cytomegalovirus,CMV)病毒感染的诊断和防治方法.方法: 回顾分析119例肝移植患者的临床资料,并结合文献进行讨论.结果: 共有8例病人术后发生活动性巨细胞病毒感染,发生率6.7%,其中2例出现发热,病人经治疗后全部治愈.结论: CMV抗体测定和FQ-PCR法测定CMV-DNA是诊断活动性巨细胞病毒感染的有效手段,更昔洛韦能够有效地防治巨细胞病毒的感染.     

肝移植病人术后巨细胞病毒感染的预防和治疗

目的 分析肝移植术后病人巨细胞病毒(CMV)感染的诊断、预防和治疗。方法 采用回顾性分析的方法，分析我科2000年8月至2002年1月期间进行的同种异体原位肝移植病例。结果 共进行同种异体原位肝移植36例。术后8例发生巨细胞病毒感染，其中2例出现腹泻，发热2例，1例为黄疸，4例无明显症状。在CMV感染的病人中，检测到CMV—IgM( )或(和)CMV-DNA( )，其中CMV—IgM( )5例，CMV-DNA( )6例。病人经更昔洛韦治疗后血清CMV-DNA变为阴性。全部治愈。结论 对病人CMV—IgM和CMV—DNA(FQ-PCR方法)联合检测应用能够对CMV感染病人作出诊断并且指导治疗。更昔洛韦能够有效的治疗CMV感染。     

Natural killer function following allogeneic bone marrow transplantation. Very early reemergence but strong dependence of cytomegalovirus infection

Natural killer (NK) cell function was followed sequentially after allogeneic bone marrow transplantation (BMT) using three approaches: (1) chromium-release assay with purified mononuclear effector cells, (2) chromium-release assay with whole blood effectors, and 3) enumeration of lymphocytes bearing the NK-associated antigen NKH-1 (N901). The two latter methods enabled us to demonstrate a very early reappearance (at day 4 posttransplant) of pre-NK cells, which after interferon-alpha enhancement effectively lysed K562 cells and carried the NKH-1 antigen. During the first month NK function steadily increased, and at day 28 activated NK cells, which lysed the otherwise resistant P815 cell line, could be demonstrated concomittant with a substantial over-shoot in the proportion of NKH-1+ cells. Furthermore, the increase in NK lysis was more pronounced in patients with cytomegalovirus (CMV) infections (primary or reactivated). In contrast, the presence of graft-versus-host (GVH) disease did not associate with consistent changes in the NK parameters measured here. After the first month of increase, NK declined reaching levels near those observed in their respective bone marrow donors at day 90. These data demonstrate a surprisingly early recovery after allogeneic BMT, which can largely be related to external factors among which CMV seems to be a prime candidate.     

Osteonecrosis of the femoral head after allogeneic bone marrow transplantation

A comparative retrospective analysis of 100 consecutive patients after bone marrow transplantation was performed with magnetic resonance imaging in addition to plain radiography for the development of osteonecrosis of the femoral head. The incidence and risk factors for osteonecrosis of the femoral head were identified, comparing various parameters concerning bone marrow transplantation between the groups with and without evidence of osteonecrosis. Nineteen (19%) of 100 patients had osteonecrosis of the femoral head develop. Four factors were found to be statistically significantly different between patients who had osteonecrosis develop and those who did not: younger age at the time of bone marrow transplantation, chronic graft-versus-host disease, cumulative dose of steroid, and intravenous pulse therapy with methylprednisolone. It was concluded that a low rate of complications and low dose steroid administration would reduce the incidence of osteonecrosis after bone marrow transplantation.     

Streptococcus pneumoniae mycotic aortic aneurysm after allogeneic bone marrow transplantation

BACKGROUND: Streptococcus pneumoniae (SP) is a common cause of community-acquired pneumonia and accounts for up to 30% of all cases of pneumonia. Patients with chronic graft-versus-host-disease (GvHD) after allogeneic bone marrow transplantation (BMT) have a high susceptibility to SP infections. So far, mycotic aneurysm resulting from SP has not been reported after BMT. METHODS: We report on a patient with extensive, chronic GvHD who developed low back pain 22 months after allogeneic BMT. RESULTS: Computed tomography of the abdomen displayed mycotic, saccular aneurysmatic enlargement of the infrarenal aorta, with leakage of contrast medium into the aneurysm. The aneurysm was resected, and the defect was closed with an autologous patch from the internal iliac artery. Bacteriologic samples from the abscess grew SP. The patient recovered uneventfully. CONCLUSIONS: This observation confirms the importance of pneumococcal prophylaxis after BMT and suggests that an aggressive diagnostic approach should always be considered in patients with chronic GvHD, even if they present with nonspecific symptoms.     

Immune reconstitution after allogeneic bone marrow transplantation depleted of T cells

BACKGROUND: Immune reconstitution following transplantation in individuals who had received T-cell-depleted marrow from HLA identical siblings was serially documented and correlated with the clinical recovery. METHODS: Patients were preconditioned with radiation containing programs. GvHD prophylaxis was by T-cell depletion with CAMPATH 1G (ex vivo; median dose 20 mg). After transplantation lymphoid development was studied by flow cytometry and serum Ig concentrations were determined. Charts were reviewed to determine the effects of the immune reconstitution on the clinical performance. RESULTS: The mean donor mononuclear cell number infused was 0.89x10(8)/kg. Within 6 months all the patients recovered their blood parameters and only one required therapy for GvHD. However, despite normal blood counts, 15 suffered life-threatening opportunistic infections, developing at a median of 24 weeks post grafting, but occurring even after 11 months. At 8 weeks from marrow infusion when leukocyte values had normalized in 15/20, compared to normal, immunophenotyping of blood cells from BMT revealed a significantly reduced mean lymphocyte count (1.06, SD 0.83x10(9)/l; P = 0.01), cells expressing CD3 (0.7x10(9)/l, SD 0.68; P = 0.05), CD4 (0.13x10(9)/l, SD 0.21; P = 0.0001) and CD19 (0.04x10(9)/l, SD 0.05; P = 0.001). Populations expressing CD8 and CD56 remained within normal range throughout the study. Normalization of cell numbers displaying CD2, CD3 and CD19 was delayed until 52, 52 and 24 weeks respectively, while CD4 counts persisted subnormal even at 72 weeks. Serum IgA levels were significantly decreased for the entire study period. CONCLUSIONS: T-cell depletion with CAMPATH 1G while effectively preventing GvHD, also causes clinically significant and prolonged immunosuppression with apparently important clinical implications.     

Hepatitis C virus infection in patients undergoing allogeneic bone marrow transplantation.

Antibody to the recently identified hepatitis C virus was investigated in sera of 128 patients treated with allogeneic bone marrow transplantation, to determine the prevalence of HCV infection and its role in post-transplant liver complications. The overall prevalence of anti-HCV positivity was 28.6% (38/128 patients). The presence of pretransplant anti-HCV positivity (in 10/35 tested patients) did not seem to predict a more severe liver disease. In fact 8/10 anti-HCV+ and 15/25 anti-HCV- patients had elevated transaminases at BMT, and posttransplant liver failure (due to VOD or subacute hepatitis), and post-BMT rises in transaminases occurred regardless of anti-HCV serology (P = 0.6 and 0.2, respectively). In patients tested for anti-HCV after BMT (n = 128), only two (one anti-HCV+ and one anti-HCV-) experienced VOD; the number of patients in whom liver failure contributed to death was comparable in anti-HCV-positive and anti-HCV- negative patients (P = 0.4). Among 17 patients with documented posttransplant seroconversion (from anti-HCV- to anti-HCV+) the appearance of anti-HCV was concomitant with hepatitis exacerbation in 9 (53%). Histologic changes demonstrated a more severe liver damage in anti-HCV+ patients: a chronic hepatitis was diagnosed in 9/11 anti-HCV+ versus 1/7 anti-HCV- cases. Based on these observations, we conclude that hepatitis C virus has a role in liver disease in such patients, although its evaluation by the anti-HCV test is still of limited accuracy, due to low sensitivity and incomplete specificity.     

Prevention of mesangial sclerosis by bone marrow transplantation

Previously we have shown that bone marrow (BM) transplantation (BMT) can attenuate progression of and even ameliorate mesangial sclerosis (MS) in Wt1-heterozygous mice. However, it is unclear whether BMT performed before the onset of disease will prevent the development of MS. To investigate whether intravenous (i.v.) or intrarenal (i.r.) administration of BM have equal effects on the progression of MS in Wt1-heterozygous mice, young Wt1-heterozygous mice that had not yet developed renal disease were used as recipients for BMT. After preconditioning with 750 cGy radiation, mice were transplanted with one million wild-type BM via i.v. or i.r. administration. All recipients and untreated controls were assessed for urinary albumin loss, renal pathology, and BM donor-derived renal cells over time. Representative kidney samples were subjected to transmission electron microscopy (TEM) analysis. Interestingly, i.r. and i.v. administration of BM cells gave comparable hematopoietic engraftment levels, and both were able to prevent the onset of MS as assessed by improved lifespan, renal function, renal histology, and TEM analysis. Taken together, we show for the first time that MS can be prevented if BMT is performed before disease onset. Similar therapeutic effects were obtained whether the BM was administered i.v. or i.r.