post-transplant infection: are we better prepared to face

LONDONLONDON’’S GLOBAL UNIVERSITYS GLOBAL UNIVERSITY

PostPost--transplant infection: are we transplant infection: are we better prepared to face the enemy?better prepared to face the enemy?

Overview of presentationOverview of presentation

Briefly summarise viruses important after transplantation

Short term and long term impact of post transplant viral infections

Review current approaches to managementPre-emptiveProphylaxisTreatment

Review the future of management and novel approaches

Viruses that can be consideredViruses that can be considered

HerpesvirusesHSV1/2VZVCMVEBVHHV-6/HHV-7HHV-8

BK virus

Adenoviruses

influenza

HIV

HBV/HCV

HPV

West Nile

Viruses to be consideredViruses to be consideredHerpesviruses

HSV1/2VZV

CMVCMVEBVEBVHHV-6/HHV-7HHVHHV--88

BK virus

Adenoviruses

Influenza

HIV

HBV/HCV

HPV

West Nile

Immunocompetent Immunocompetent Host:Host:

Persistent/latent virus in Persistent/latent virus in harmony with its hostharmony with its host

VIRUSVIRUSIMMUNE IMMUNE SYSTEMSYSTEM

Immunocompromised Immunocompromised host:host:

Persistent/latent viruses has Persistent/latent viruses has the upper handthe upper hand

VIRUSVIRUS

IMMUNE IMMUNE SYSTEMSYSTEM

Immunocompromised Immunocompromised host:host:Subtle immune improvement can help Subtle immune improvement can help

control Persistent/latent virusescontrol Persistent/latent viruses

IMMUNE IMMUNE SYSTEMSYSTEM

VIRUSVIRUS

CMV InfectionCMV Infection

HCMV replication in the human hostHCMV replication in the human host•• BetaherpesvirusBetaherpesvirus•• Latent in Latent in monocytes monocytes and BM progenitor cellsand BM progenitor cells•• Seroprevalence Seroprevalence about 60%about 60%•• In active replication In active replication -- highly dynamichighly dynamic

•• Doubling time ~ 1 dayDoubling time ~ 1 day•• Peak viral load correlates with HCMV disease after Peak viral load correlates with HCMV disease after

transplanttransplant•• In addition to peak viral loads, lower levels of In addition to peak viral loads, lower levels of

persistent replication are also important for persistent replication are also important for pathogenesispathogenesis

•• DonDon’’t forget the immune systemt forget the immune systemEmery VC et al (1999) Emery VC et al (1999) J.Exp.Med.J.Exp.Med. 190:177190:177--82;82; Emery and Griffiths Emery and Griffiths (2000) (2000) PNASPNAS97(14):8039-44;; Regoes Regoes R R ……Emery VC (2006) Emery VC (2006) Proc. Proc. BiolBiol. . SciSci. 273:1961. 273:1961--77

Quality of the Immune Quality of the Immune responseresponse

•• In some, but not all studies, failure to control HCMV replicatioIn some, but not all studies, failure to control HCMV replication associated n associated with subwith sub--optimal responses in both CD4 and CD8 compartmentsoptimal responses in both CD4 and CD8 compartments1,2,31,2,3

•• Protection against HCMV disease after heart/heartProtection against HCMV disease after heart/heart--lung transplantation lung transplantation associated with a CD8 IEassociated with a CD8 IE--1 responses1 responses44

•• Protection against HCMV replication after SCT associated with exProtection against HCMV replication after SCT associated with expansion of pansion of IE1 specific CD8 TIE1 specific CD8 T--cellscells55

•• Early CD4 HCMV TEarly CD4 HCMV T--cell responses after heart transplantation protect against cell responses after heart transplantation protect against long term indirect effectslong term indirect effects66

•• The proportion of The proportion of tettet+ CD8 T+ CD8 T--cells producing cells producing IFNIFNγγ is an important factor in is an important factor in controlling high level replicationcontrolling high level replication77 and progression to HCMV diseaseand progression to HCMV disease88

•• Polyfunctional Polyfunctional CD8 TCD8 T--cells against HCMV predictive of viral replicationcells against HCMV predictive of viral replication2 2

•• Level of CD45Ra expression on HCMV CD8 TLevel of CD45Ra expression on HCMV CD8 T--cells associated with duration cells associated with duration of replicationof replication1010

1) 1) Gerna Gerna G et al. G et al. Am J Transplant.Am J Transplant. 2006; 6:23562006; 6:2356--2364. 2) 2364. 2) Nebbia Nebbia G et al (2008) Am J Transplant eG et al (2008) Am J Transplant e--pub. pub. 3) La Rosa et al (2007) JID 195:6333) La Rosa et al (2007) JID 195:633--44. 4) 44. 4) Bunde Bunde et al (2005), et al (2005), J.Exp.MedJ.Exp.Med 201:1031201:1031--3636 5) 5) Sacre Sacre et al et al (2008) J (2008) J Virol Virol 82: 1014382: 10143--52 6) 52 6) Tu Tu W et al (2006) Circulation 114: 1608W et al (2006) Circulation 114: 1608--15. 7) 15. 7) Mattes et al (2008) Am J Mattes et al (2008) Am J Transplant 8:990Transplant 8:990--99 8) 99 8) Crough Crough T et al (2007) J T et al (2007) J Virol Virol 81:1153881:11538--42. 9) 42. 9) Cantisan Cantisan et al (2010) et al (2010) Clin Immunol Clin Immunol 137:81137:81--88.88.

Effects of HCMV post solid Effects of HCMV post solid organ transplantationorgan transplantation

•• Direct effectsDirect effects•• Prolonged feverProlonged fever•• LeukopeniaLeukopenia•• PneumonitisPneumonitis•• HepatitisHepatitis•• GI diseaseGI disease•• RetinitisRetinitis•• myocarditismyocarditis

•• Indirect effectsIndirect effects•• Acute rejectionAcute rejection•• Long term graft Long term graft

functionfunction•• Atherosclerosis (CAD)Atherosclerosis (CAD)•• Vascular diseaseVascular disease•• Post transplant Post transplant

diabetesdiabetes•• Bronchiolitis obliteransBronchiolitis obliterans•• Opportunistic bacterial, Opportunistic bacterial,

fungal infectionsfungal infections

HCMV: The Indirect effectsHCMV: The Indirect effects

•• High viral loads may not be necessaryHigh viral loads may not be necessary•• Risk factors identified include: Risk factors identified include:

•• HCMV HCMV seropositivity seropositivity •• Low level HCMV replication Low level HCMV replication

(asymptomatic (asymptomatic viremiaviremia))•• High level HCMV replication and HCMV High level HCMV replication and HCMV

diseasedisease

New onset diabetes mellitus in patients New onset diabetes mellitus in patients with asymptomatic HCMV with asymptomatic HCMV viremiaviremia

Adapted from J Adapted from J HjelmesHjelmesææth th et al. et al. DiabetologiaDiabetologia 2004; 47:15502004; 47:1550--6.6.

0

5

10

15

20

25

30

AsymptomaticHCMV infection

No HCMVinfection

Pat

ient

s w

ith P

TDM

(%)

p = 0.003

16/61

4/63

26%

6%

The Impact of HCMV Infection and The Impact of HCMV Infection and Disease on Rejection Episodes in Disease on Rejection Episodes in

Renal Allograft RecipientsRenal Allograft Recipients•• Analysis of 477 consecutive renal allograft Analysis of 477 consecutive renal allograft

recipientsrecipients•• HCMV infection and disease examined HCMV infection and disease examined

prospectively for 3 monthsprospectively for 3 months•• No HCMV prophylaxis was given, and HCMV No HCMV prophylaxis was given, and HCMV

disease treateddisease treated•• Acute rejection associated withAcute rejection associated with

•• HCMV infection (odds ratio = 1.6; p=0.02)HCMV infection (odds ratio = 1.6; p=0.02)•• HCMV disease (odds ratio = 2.5; p=0.01)HCMV disease (odds ratio = 2.5; p=0.01)

Sagedal Sagedal S. S. et al. Am J Transplantet al. Am J Transplant 2002; 2: 8502002; 2: 850--856856

Extensive presence of HCMV DNA Extensive presence of HCMV DNA in Renal Biopsiesin Renal Biopsies

•• Extensive infectionExtensive infection•• 60% biopsies HCMV DNA 60% biopsies HCMV DNA

positive (50% patients)positive (50% patients)•• ~ 80% of biopsy +~ 80% of biopsy +ve ve patients patients

developed HCMV developed HCMV DNAemia DNAemia •• HCMV DNA present in patients HCMV DNA present in patients

with and without concurrent with and without concurrent acute rejectionacute rejection

•• Some patients with HCMV in Some patients with HCMV in biopsy developed acute biopsy developed acute rejection subsequentlyrejection subsequently

•• Patients who developed HCMV Patients who developed HCMV disease had positive biopsy for disease had positive biopsy for HCMVHCMV

Li T, Emery VC et al (2009) J Med Li T, Emery VC et al (2009) J Med Virol Virol 82:8582:85--9393

Creatinine Creatinine levels are elevated in levels are elevated in patients with HCMV DNA in biopsypatients with HCMV DNA in biopsy

050

100150200250300350400450500550

3 12 24 36 60Months post transplant

No HCMVDNAHCMV DNAPOS

*

* P = 0.04

Li T, Emery VC et al (2009) J Med Li T, Emery VC et al (2009) J Med Virol Virol 82:8582:85--9393

HCMV and long term kidney HCMV and long term kidney graft functiongraft function

•• In situ detection of HCMV in renal biopsiesIn situ detection of HCMV in renal biopsies•• Patients with persistent Patients with persistent intragraft intragraft HCMV had:HCMV had:

•• reduced graft survival (OR=3.5; p=0.03)reduced graft survival (OR=3.5; p=0.03)•• reduced reduced creatinine creatinine clearance at:clearance at:

•• 1 year (OR=5.1; p=0.01) and 1 year (OR=5.1; p=0.01) and •• 2 years (OR=4.3;p=0.03) post transplant2 years (OR=4.3;p=0.03) post transplant

•• In multivariable analysis HCMV was the In multivariable analysis HCMV was the only risk factor for lower only risk factor for lower creatinine creatinine clearance at 2 years (OR=4.9;p=0.02)clearance at 2 years (OR=4.9;p=0.02)

HelanterHelanterää I et al.(2006) I et al.(2006) TransplTranspl. . IntInt.. 19:89319:893--900.900.

Therapeutic approaches to control Therapeutic approaches to control HCMV replicationHCMV replication

ProphylaxisUniversal or targetedEliminates direct and indirect effects of HCMVSubset of patients remain at risk of late CMV infection/disease after cessation of prophylaxis

Pre-emptive therapyInitiated based on virologic markers Minimises drug exposurePatients may require more than one treatmentMay not eliminate the indirect effects of HCMV

Forum debate (2001) Forum debate (2001) Rev. Med. Rev. Med. VirolVirol.. 11:7311:73--8686

Small LN et al (2006) Small LN et al (2006) ClinClin. Infect. . Infect. DisDis.43, 869.43, 869--8080

HCMV pathogenesis: a modelHCMV pathogenesis: a model

QuickTime™ and a decompressor

are needed to see this picture.















Acute graft dysfunction Long-term graft

dysfunction

High level High level DNAemiaDNAemia

HCMV HCMV DiseaseDisease

Donor organDonor organ

day0

Days 3-7

Days

7-20

TNF-α, inflammation

TNF-α

Days Days 77--3030

Other organs

Days 35-40

Months/years

weeks

Li, Emery et al (2009) J Med Li, Emery et al (2009) J Med Virol Virol 82:8582:85--9393

HCMV pathogenesis: PreHCMV pathogenesis: Pre--emptive therapyemptive therapy


















dysfunction


day0

Days 3-7

Days

7-20


TNF-α

Days Days 77--3030

Other organs

Days 35-40

Months/years

weeks



HCMV pathogenesis: prophylaxisHCMV pathogenesis: prophylaxis


dysfunction


day0

Days 3-7

Days

7-20


TNF-α

Months/years

weeks



















Days Days 77--3030

Other organs

Days 35-40

Guidelines for the management of Guidelines for the management of HCMV following transplantationHCMV following transplantation

National guidelines (out of date)UK guidelines (2002)Australian and American guidelines (2004)Canadian guidelines (2005)

KDIGO guidelines (2009)

TTS consensus guidelines published in 2010*

British Transplantation Society Guidelines. Published by the British Transplantation Society, 2002.The CARI Guidelines. Nephrology 2004; 9 (Issue s3):S23-40.

Am J Transplant 2004; 4 (Suppl.10):51-8.Preiksaitis JK et al. Am J Transplant 2005; 5:218-27.

*Cotton K et al 2010. Transplantation 89:779-95

Prophylaxis and preemptive strategies Prophylaxis and preemptive strategies both reduce the development of CMV both reduce the development of CMV diseasedisease

Bacterial and fungal infections and death statistically reduced by universal prophylaxis, but not by preemptive therapy

0.1 0.2 0.5 1 2 5 10

Overall effect of preemptive trials

Overall effect of universal prophylaxistrials

Odds ratio (95% CI)

0.28

0.20

Favors Treatment Favors Control

Kalil Kalil AC et al. AC et al. Ann Intern Med Ann Intern Med 2005; 143:8702005; 143:870--80.80.

HCMV load cutHCMV load cut--offs to initiate offs to initiate prepre--emptive therapyemptive therapy

•• In the absence of a universal standard difficult to compare In the absence of a universal standard difficult to compare between laboratoriesbetween laboratories

•• At our centre we use 3000 ge/ml blood At our centre we use 3000 ge/ml blood •• Other studies have used Other studies have used antigenemia antigenemia > 50 +> 50 +ve ve

cells/400,000 leukocytes in renal patientscells/400,000 leukocytes in renal patients11

•• Equivalent to ~ 8,600 ge/ml bloodEquivalent to ~ 8,600 ge/ml blood•• RCT of RCT of DNAemia DNAemia (>300,000 ge/ml) vs (>300,000 ge/ml) vs Agemia Agemia (>100 +(>100 +ve ve

cells) in SOT patientscells) in SOT patients22 reported that:reported that:•• 23/99 patients treated in the 23/99 patients treated in the DNAemia DNAemia arm compared to arm compared to

42/101 patients in the 42/101 patients in the Antigenemia Antigenemia arm (p=0.01) arm (p=0.01) •• 4 cases of disease4 cases of disease

•• Universal HCMV DNA standard requiredUniversal HCMV DNA standard required

1.Kim et al (2007) Transplant Proc 39, 1458-60; 2.Gerna G (2007) Antiviral Therapy 12:63-72

Prospective randomised trial Prospective randomised trial comparing preemptive therapy comparing preemptive therapy with prophylaxiswith prophylaxisStudy aims:

To determine ifCMV prophylaxis with oral ganciclovir is superior compared to IV preemptive therapyOral prophylaxis prevents graft exposure to CMV

Effects of both treatments on long-term graft survival

Kliem V et al. Kliem V et al. Am J TransplantAm J Transplant 2008; 8:9752008; 8:975--83.83.

Prophylaxis prolongs time to first CMV Prophylaxis prolongs time to first CMV infectioninfection

100

9080

70

60

50

40

30

0 0 60 120 180 240 270 360

IV preemptive therapy

Oral prophylaxis

p value (Log rank test) < 0.0001

Free

dom

from

CM

V In

fect

ion

(%)

Time after transplantation (days)Kliem V et al. Kliem V et al. Am J TransplantAm J Transplant 2008; 8:9752008; 8:975--83.83.

Prophylaxis period

HCMV prophylaxis is associated with HCMV prophylaxis is associated with improved longimproved long--term graft survivalterm graft survival

1009080706050

0

Oral prophylaxis

IV preemptive therapy

Free

dom

from

gra

ft lo

ss(u

ncen

sore

d fo

r dea

th; %

)

1 2 3 4Time after transplantation (years)

Kliem V et al. Kliem V et al. Am J TransplantAm J Transplant 2008; 8:9752008; 8:975--83.83.

p value (Log rank test) = 0.0425

0

Treatment of HCMV Disease Treatment of HCMV Disease --What do current guidelines say?What do current guidelines say?

Intravenous ganciclovir (5mg/kg bid) or

valganciclovir (900mg bid)

Severe life threatening disease should be treated with iv GCV

Treatment should continue until eradication of viraemia and secondary prophylaxis may be considered

Both formulations require dose adjustment for renal function

Cotton K et al 2010. Transplantation 89:889Cotton K et al 2010. Transplantation 89:889--9595

Treatment of HCMV disease: Treatment of HCMV disease: VICTOR studyVICTOR study

Asberg Asberg et al. Am J Transplant et al. Am J Transplant 2007;7:21062007;7:2106––1313

Cum

ulat

ive

prob

abili

ty o

f per

sist

ant

activ

e C

MV

dise

ase

Cum

ulat

ive

prob

abili

ty o

f pe

rsis

tant

vira

emia

Days of observationDays of observation

Oral Oral valganciclovirvalganciclovir Intravenous Intravenous ganciclovirganciclovir

1.0

0.8

0.6

0.4

0.2

0.0

0 7 14 21 4928 35 42

1.0

0.8

0.6

0.4

0.2

0.0

0 7 14 21 564928 35 42

DNAemia Disease

Long term outcomes from Long term outcomes from VICTORVICTOR

•• In the VICTOR study recurrence of clinical and In the VICTOR study recurrence of clinical and virological virological endpoints was 15.1% and 30%endpoints was 15.1% and 30%

•• Major risk for recurrence was failure to eradicate Major risk for recurrence was failure to eradicate HCMV plasma DNA by day 21HCMV plasma DNA by day 21•• Clinical endpoints OR 3.4; p=0.012Clinical endpoints OR 3.4; p=0.012•• Virologic Virologic endpoint OR 5.6; p<0.0001endpoint OR 5.6; p<0.0001

•• GCV resistance developed in 8 patientsGCV resistance developed in 8 patients•• No differences in long term outcomes between No differences in long term outcomes between

treatment armstreatment arms

Asberg Asberg A et al (2009) Am J Transplant 9; 1205A et al (2009) Am J Transplant 9; 1205--1111

Failure to Eradicate at D21Failure to Eradicate at D21Predicts RecurrencePredicts Recurrence

Odds ratio: 6.23 p=0.008

days of observation300250200150100500

cum

ulat

ive

prob

abili

ty o

f per

sist

ance

in re

mis

sion

1.00

0.98

0.96

0.94

0.92

0.90

failure

success

P=0.004

Asberg Asberg et al Am J Transplant. 9:1205et al Am J Transplant. 9:1205--1213, 20091213, 2009

Optimal duration of prophylaxis Optimal duration of prophylaxis --What do current guidelines say?What do current guidelines say?

3 months - 6 months prophylaxis should be used in D+R- patients

Decision based on immunosuppression and type of transplantDosing should be optimal

Minimum of 6 months for lung and small intestine receipients

Preiksaitis JK et al. (2005) Preiksaitis JK et al. (2005) Am J Transplant Am J Transplant 5:2185:218--2727Cotton K et al (2010) Transplantation 89:779Cotton K et al (2010) Transplantation 89:779--9595

Study Design Study Design -- IMPACTIMPACT(D+R(D+R-- Renal transplant patients)Renal transplant patients)

Humar Humar A et al (2010) Am J Transplant 10:1228A et al (2010) Am J Transplant 10:1228--3737

Confirmed CMV DiseaseConfirmed CMV Disease


Incidence of Incidence of ViremiaViremia


GCV resistanceGCV resistance•• Two loci involvedTwo loci involved

•• UL97UL97•• UL54UL54

•• Relatively small number of mutations in UL97 Relatively small number of mutations in UL97 associated with GCVassociated with GCVrr

•• M460, L595, A594, H520, E596, C603, C607M460, L595, A594, H520, E596, C603, C607•• Resistance at UL54 locus more complex but usually Resistance at UL54 locus more complex but usually

occurs after UL97 mutations in GCV resistanceoccurs after UL97 mutations in GCV resistance•• Frequency of GCVFrequency of GCVr r relatively low in transplant setting but relatively low in transplant setting but

promoted by:promoted by:•• SubSub--optimal therapyoptimal therapy•• Very long term therapy especially in patients with ongoing Very long term therapy especially in patients with ongoing

DNAemiaDNAemia

•• Suspect GCVSuspect GCVrr if persistent high HCMV loads or if persistent high HCMV loads or progression of clinical diseaseprogression of clinical disease11

Cotton K et al (2010). Transplantation 89:779-95

Are we better prepared for CMV?Are we better prepared for CMV?

Not bad!Not bad!Better understanding of pathogenesis and immune controlBetter understanding of pathogenesis and immune controlProphylaxis in high risk patientsProphylaxis in high risk patientsPrePre--emptive therapyemptive therapyAvailability of oral Availability of oral valganciclovir valganciclovir Drug resistance not a major problemDrug resistance not a major problemEncouraging data from vaccine studiesEncouraging data from vaccine studies

Remaining issuesRemaining issuesIdentifying patients at high risk of infection and its long termIdentifying patients at high risk of infection and its long termconsequenceconsequenceManagement of post prophylaxis infection/disease Management of post prophylaxis infection/disease Very few new drugs on the horizon (maribavir failed phase 3 studVery few new drugs on the horizon (maribavir failed phase 3 studies)ies)

BK Viral InfectionsBK Viral Infections

BK VirusBK Virus• Ubiquitous virus member of the polyomaviruses• Natural virus infection occurs in childhood • Latent in kidney epithelium• Serological prevalence 90% and stable since virus discovery in

the 1970s• Immuncompetent adults intermittent reactivation

– 5 - 10% at viral loads about 3,000 ge/ml urine• Active infection more common in immunocompromised

– 20-60% with much higher viral loads• Incidence of BKV nephropathy (PVAN) following transplantation

2-8%• 45% of biopsy positive patients will loose graft• Mutations in the non-coding control region1 associated with:

– 20-fold increase in plasma viral load– More extensive inflammation – Higher replication capacity

1. Gosert et al (2008) J Exp Med 205:841-52

Immune control of BKVImmune control of BKV• BKV neutralising antibodies target the VP1 capsid protein

– Accelerate BKV clearance during primary infection– Protect agianst BK viraemia– weak role in resolving disease

• In patients with haemorrhagic cystitis, T-cell proliferation occurs and may drive pathology

• In the case of PVAN evidence supports a key role for CD8 T-cells in resolving infection/disease

• CD8 T-cells target a range of proteins including large T, small t and VP1,2,3

• Frequency of IFN gamma CD8 T-cells is relatively low for both VP1 and large T (~0.3%)

• Threshold levels of BKV large T-antigen cells may be important in protection against BKV replication

Reviewed by Reviewed by Comoli Comoli et al (2008) et al (2008) Curr Curr Opinion in Org Transplant 13:569Opinion in Org Transplant 13:569--7474

Diagnosis of BK virus and Diagnosis of BK virus and PVANPVAN

•• Primary screening usually by urine cytology (every 3 Primary screening usually by urine cytology (every 3 months)months)–– Presence of decoy cells triggers more frequent surveillance Presence of decoy cells triggers more frequent surveillance

and/or biopsyand/or biopsy•• Biopsy provides a picture of PVANBiopsy provides a picture of PVAN

–– Various patterns can be observed and staining with anti Various patterns can be observed and staining with anti SV40 LT Ag antibodies definitiveSV40 LT Ag antibodies definitive

•• Screening with real time PCR of urine and blood has Screening with real time PCR of urine and blood has become more commonbecome more common–– Very high loads in urineVery high loads in urine–– BK BK viraemia viraemia is associated with PVANis associated with PVAN

•• Key message is that early diagnosis and preKey message is that early diagnosis and pre--emptive emptive therapy is key to therapy is key to minimise minimise graft lossgraft loss

Acute rejection vs PVANAcute rejection vs PVAN



Tubulitis Tubulitis with with Lymphocytic Lymphocytic infiltratesinfiltrates

Nuclear Nuclear staining with staining with antibodies to antibodies to SV40 LTSV40 LT--AgAg

Taken from Ramos et al (2009) Transplantation 87:621Taken from Ramos et al (2009) Transplantation 87:621--3030

Biopsy sampling and PVANBiopsy sampling and PVAN



Ab SV40 LT

Ab SV40 LT

Ab SV40 LT


Efficacy of quantitative BKV monitoringEfficacy of quantitative BKV monitoring

• BK load (real time PCR) in:– Urine,plasma, kidney biopsies

• Patients with asymptomatic viruria, BKVAN, and resolved BKVAN

• BKVAN associated with:– BK viremia > 5 x 103 ge/mL– BK viruria > 1 x 107 ge/mL

• Resolved BKVAN associated with lower viral loads in urine

Randhawa et al (2004) J Clin Micro 42; 1176-80

Urine BKV loads higher in patients Urine BKV loads higher in patients with BKV plasma with BKV plasma viraemiaviraemia



Funk et al (2008) Am J Transplant 8:2268Funk et al (2008) Am J Transplant 8:2268--7777

Natural History of BKV/PVANNatural History of BKV/PVAN




Incidence and treatment of Incidence and treatment of PVANPVAN•• Two large series publishedTwo large series published

•• OPTN analysis included 48,292 OPTN analysis included 48,292 RTx RTx patients from patients from 20032003--2006200611

•• National SRTR database (also derived from the National SRTR database (also derived from the OPTN included 48,838 patientsOPTN included 48,838 patients22

•• Treated BKV infection rising in recent years (OR Treated BKV infection rising in recent years (OR 1.69)1.69)

•• Kaplan Meier estimates for treated BK virus were:Kaplan Meier estimates for treated BK virus were:–– Between 0.7 Between 0.7 -- 1.6% at 6 months1.6% at 6 months–– Between 2.6Between 2.6--2.8% at 12 months 2.8% at 12 months –– 6.6% at 5 years6.6% at 5 years

•• Graft survival estimates at 6 months were:Graft survival estimates at 6 months were:–– 90% in patients with no BKV90% in patients with no BKV–– 79% in patients with BKV79% in patients with BKV

1. Dharnidharka et al (2009) 87:1019-26; 2. Schold et al (2009) Transplant International 22:626-34

Patient and graft survival Patient and graft survival with or without BKVwith or without BKV



Schold et al (2009) Transplant International 22:626-34

Risk Factors for PVANRisk Factors for PVAN• A number of risk factors identified although

one of the most important is the quantity of immunosppression

• Factors increasing risk include:– MMF and Tacrolimus based regimens– Induction therapy especially with thymoglobulin– Male gender– Acute rejection episode in 1st 6 months– HLA mismatch– Donor age and peadiatric recipients

Management of PVANManagement of PVAN• Mainstay has been reduction in immunosuppresion

– When and by how much?• Reconstitution of the immune response against BKV takes 4-

12 weeks so start early• Reduced immunosuppression can lead to AR but if reduction

occurs early then AR may be 10-15%• Several protocols (Maryland):

– Step 1: reduce MMF by 50% after diagnosis– Step 2: 50% decrease in target trough levels of

tacrolimus if decpy cells persist– Step 3: eliminate MMF at 6 months if decoy cells persist– Maintenance immunosuppression with low dose

tacrolimus and prednisone (not exceeding 7.5-15mg/week)

Antiviral therapy for PVANAntiviral therapy for PVAN•• No agents approved by the FDANo agents approved by the FDA•• A range of agents used including:A range of agents used including:

–– CidofovirCidofovir, immunoglobulin,, immunoglobulin,leflunomideleflunomide•• No prospective trials undertaken and all reports No prospective trials undertaken and all reports

also reduce also reduce immunosuppressionimmunosuppression•• Very few studies combine high quality Very few studies combine high quality virologicalvirological, ,

clinical and immune monitoring post interventionclinical and immune monitoring post intervention•• Doses of Doses of cidofovir cidofovir and and leflunomide leflunomide required to required to

inhibit BKV replication in vitro are much higher inhibit BKV replication in vitro are much higher than those achieved in vivo using current dosing than those achieved in vivo using current dosing regimensregimens

•• No new agents in the pipelineNo new agents in the pipeline

Case 1Case 1• 42 year old female with prior history of familial pancreatitis,

diabetes mellitus• Underwent partial pancreatectomy and splenectomy at age

23/25 years• Full splenectomy at age 37• Kidney-pancreas transplant 2007• Good course for 1st year on Tacrolimus and MMF• Day 405 admitted with MRSA and increasing creatinine levels• Renal ultrasound normal

Next steps?Next steps?

•• A) perform renal biopsyA) perform renal biopsy•• B) B) analyse analyse urine for BK virus inclusionsurine for BK virus inclusions•• C) perform BKV PCR on bloodC) perform BKV PCR on blood•• D) all of the aboveD) all of the above

Case 1: progressCase 1: progress

•• Renal biopsy shows features of BKV infection although no chronicRenal biopsy shows features of BKV infection although no chronicdamagedamage

•• Urine viral inclusions present Urine viral inclusions present •• BKV PCR of blood shows a viral load of 26,000 genomes/mlBKV PCR of blood shows a viral load of 26,000 genomes/ml

Patient Management decisionPatient Management decision

•• A) BKV nephropathy stop MMFA) BKV nephropathy stop MMF•• B) BKV nephropathy so initiate B) BKV nephropathy so initiate cidofovir cidofovir therapy therapy •• C) BKV nephropathy so stop MMF and initiate C) BKV nephropathy so stop MMF and initiate

cidofovir cidofovir therapy therapy •• D) wait and see if D) wait and see if creatinine creatinine levels levels stabilisestabilise


•• MMF stoppedMMF stopped•• Creatinine Creatinine levels levels stabilise stabilise for 1 monthfor 1 month•• Day 441 admitted for rising Day 441 admitted for rising creatininecreatinine

–– Biopsy confirms severe BKV infection,Biopsy confirms severe BKV infection,–– No rejectionNo rejection–– BKV DNA in blood 110,000 ge/mlBKV DNA in blood 110,000 ge/ml


•• Placed on Placed on cidofovircidofovir•• BKV levels reduce on BKV levels reduce on cidofovir cidofovir over the next 4 weeksover the next 4 weeks•• At day 500 admitted with high At day 500 admitted with high creatininecreatinine

–– Tacrolimus Tacrolimus reduced to 2mg bdreduced to 2mg bd•• At day 530 rising At day 530 rising creatinine creatinine but BKV DNA level in but BKV DNA level in

blood 50 ge/mlblood 50 ge/ml•• Cidofovir Cidofovir rere--started 15mg iv fortnightlystarted 15mg iv fortnightly•• BKV load in blood at day 565 at 30,000 ge/mlBKV load in blood at day 565 at 30,000 ge/ml•• ReRe--admitted at day 572 with lethargy and rising admitted at day 572 with lethargy and rising

creatininecreatinine•• Renal biopsy shows persistent BKV infection but no Renal biopsy shows persistent BKV infection but no

rejectionrejection

Case 1 Case 1 --optionsoptions

A)A) Continue Continue cidofovir cidofovir therapytherapyB)B) Stop Stop cidofovir cidofovir and and Tacrolimus Tacrolimus and initiate and initiate

leflunomide leflunomide therapytherapyC)C) Remove kidneyRemove kidney

Are we better prepared for BKV?Are we better prepared for BKV?

•• Not really!Not really!•• Reduction in Reduction in immunosuppression immunosuppression is first line is first line

approachapproach–– Earlier is better Earlier is better

•• Lack of data on efficacy of Lack of data on efficacy of antiviralsantivirals•• No new drugs in the pipelineNo new drugs in the pipeline

EBV InfectionEBV Infection

EBV InfectionEBV Infection•• High High seroprevalenceseroprevalence, member of the , member of the gammaherpesvirus gammaherpesvirus familyfamily•• 173kB genome173kB genome•• EBV can infect B and T lymphocytes, EBV can infect B and T lymphocytes, squamous squamous epithelial cells of epithelial cells of

the the orooro-- and and nasopharynxnasopharynx, glandular epithelial cells and , glandular epithelial cells and SMCs SMCs and and DCsDCs

•• EBV linked to a range of benign and EBV linked to a range of benign and neoplastic neoplastic human diseases:human diseases:•• NPC and PTLD (>95% EBV)NPC and PTLD (>95% EBV)•• Hodgkins Hodgkins lymphoma and NHL (5lymphoma and NHL (5--95% EBV)95% EBV)•• Oral hairy Oral hairy leukoplakia leukoplakia (>95%)(>95%)

•• EBV specific CD8 TEBV specific CD8 T--cells control EBV transformed cells during cells control EBV transformed cells during primary infectionprimary infection

•• Virus undergoes frequent reactivation in the Virus undergoes frequent reactivation in the immunocompetent immunocompetent host host without causing pathologywithout causing pathology

•• Reductions in CD8 TReductions in CD8 T--cell control results in high levels of EBV cell control results in high levels of EBV replication including infection of bystander cells and leads to replication including infection of bystander cells and leads to pathological consequencespathological consequences

EBV Infection after transplantationEBV Infection after transplantation

•• Active EBV infection relatively commonActive EBV infection relatively common•• Closely linked to degree of Closely linked to degree of

immunosuppressionimmunosuppression•• Subset of patients at risk of developing Subset of patients at risk of developing

pathological consequences of EBV in pathological consequences of EBV in particular PTLDparticular PTLD

•• Viral replication can be reduced by Viral replication can be reduced by antiviral prophylaxis with antiviral prophylaxis with ACV,VACV,GCV and VGCVACV,VACV,GCV and VGCV

•• Antiviral agents have no effect against Antiviral agents have no effect against latently infected or transformed Blatently infected or transformed B--cellscells

Incidence of EBV infection after Incidence of EBV infection after transplantationtransplantation

148 (56.3%)148 (56.3%)Overall (n=263)Overall (n=263)52 (56.5%)52 (56.5%)Renal (n=92)Renal (n=92)22 (48.9%)22 (48.9%)Heart (n=45)Heart (n=45)72 (59.5%)72 (59.5%)Liver (n=121)Liver (n=121)EBV EBV DNAemiaDNAemia****Transplant typeTransplant type**

*Patients received oral GCV or valganciclovir prophylaxis

** Baseline incidence of EBV DNAemia was 16.8%

Razonable Razonable R et al (2005) R et al (2005) J. Infect. J. Infect. DisDis.. 192, 1331192, 1331--99

Post transplant Post transplant lymphoproliferative lymphoproliferative disease (PTLD)disease (PTLD)

•• Common tumour in transplant patientsCommon tumour in transplant patients•• Associated with latency type IIIAssociated with latency type III

•• EBNAs EBNAs 1,2,3A,3B,3C, LP, LMP1,LMP2 and 1,2,3A,3B,3C, LP, LMP1,LMP2 and EBERsEBERs•• Incidence varies between different transplant groups and Incidence varies between different transplant groups and

greatest in greatest in peadiatric peadiatric transplantationtransplantation•• >90% tumours are associated with EBV>90% tumours are associated with EBV•• Clinically and morphologically diverseClinically and morphologically diverse•• Highest incidence in the first 1Highest incidence in the first 1--2 years2 years•• Relapses common and mortality high (>50%)Relapses common and mortality high (>50%)

Incidence of PTLDIncidence of PTLD

NANA2020Small bowelSmall bowel6.4 6.4 -- 19.519.54.2 4.2 -- 1010LungLung6.4 6.4 -- 19.519.52.4 2.4 -- 5.85.8HeartHeart--lunglung6.4 6.4 -- 19.519.511-- 6.36.3HeartHeart4 4 -- 15%15%1 1 -- 2.82.8LiverLiver1.2 1.2 -- 10.110.11 1 -- 2.32.3RenalRenalChildrenChildrenAdultAdult

Incidence (%)Incidence (%)Type of Type of TransplantTransplant

Reviewed by Taylor et al (2005) Critical Reviews in Oncology/Reviewed by Taylor et al (2005) Critical Reviews in Oncology/Haematology Haematology 56, 15556, 155--6767

Risk factors for PTLD developmentRisk factors for PTLD development•• Degree of Degree of immunosuppression immunosuppression (IS)(IS)

• Type of Transplant• Donor-recipient HLA-mismatch (liver, heart &/or lung)• Repeated episodes of rejection• Re-transplantation• Bone marrow/HSCT

• T cell depletion (Incidence up to 24%)• Unrelated or HLA-mismatched donors• Use of ATG or anti-CD3 monoclonal Ab (OKT3)

Risk factors for PTLD developmentRisk factors for PTLD development

•• EpsteinEpstein--Barr VirusBarr Virus

•• EBV EBV seronegativity seronegativity at transplantat transplant•• Primary EBV infection following transplantationPrimary EBV infection following transplantation•• Mostly childrenMostly children•• Organ donor is EBV Organ donor is EBV seropositiveseropositive

•• Reactivation of preReactivation of pre--existing EBV infectionexisting EBV infection•• Usually in adultsUsually in adults

Clinical presentations of PTLDClinical presentations of PTLD•• Infectious monoInfectious mono--like illness: like illness:

•• Primary EBV infection in previously Primary EBV infection in previously seronegative seronegative patients, mostly childrenpatients, mostly children

•• Fever, sore throat, Fever, sore throat, lymphadenopathylymphadenopathy, enlarged liver & , enlarged liver & spleen, diarrhoea, weight loss, anaemiaspleen, diarrhoea, weight loss, anaemia

•• Nodal and/or Nodal and/or extranodalextranodal: : •• EBV EBV seropositiveseropositive•• Single or multiple sitesSingle or multiple sites•• Common in transplanted organ, bowel, CNSCommon in transplanted organ, bowel, CNS

Role of EBV load monitoring in Role of EBV load monitoring in predicting PTLDpredicting PTLD

•• EBV loads are elevated at the time EBV loads are elevated at the time of PTLDof PTLD

•• However, role of sequential EBV However, role of sequential EBV load measures to identify patients load measures to identify patients at risk of PTLD more controversial at risk of PTLD more controversial

•• Differences in Differences in analyte analyte also also important important •• Whole blood Whole blood •• Plasma/serumPlasma/serum

Treatment of PTLDTreatment of PTLD•• Reduction of Reduction of immunosuppressionimmunosuppression•• Antivirals Antivirals ((acicloviraciclovir, , ganciclovirganciclovir))•• ChemotherapyChemotherapy•• SurgerySurgery•• RadiotherapyRadiotherapy•• RituximabRituximab, , mAb mAb against CD20 expressed against CD20 expressed

on B cell surfaceon B cell surface•• EBVEBV--specific specific cytotoxic cytotoxic T lymphocytes T lymphocytes

(CTL)(CTL)

Antiviral prophylaxis and EBV Antiviral prophylaxis and EBV replicationreplication

02468

10

>1000 >2000 >5000EBV load ge/ml whole blood

oral GCVValGCV

•• Valganciclovir Valganciclovir achieves higher levels of GCVachieves higher levels of GCV

•• better control of high level EBV replication (p=0.03)better control of high level EBV replication (p=0.03)

Razonable Razonable R et al (2005) R et al (2005) J. Infect.J. Infect. DisDis.. 192, 1331192, 1331--99

Rituximab Rituximab to control PTLDto control PTLD

•• Rituximab Rituximab results in a profound longresults in a profound long--lasting depletion of lasting depletion of B lymphocytesB lymphocytes

•• Three clinical trials reported in SOTThree clinical trials reported in SOT•• 4 weekly injections of 4 weekly injections of rituximab rituximab (375 mg/m(375 mg/m22))•• Response rate between 44.2% and 64.0%Response rate between 44.2% and 64.0%•• Survival rates ~67%Survival rates ~67%•• Relapse rate in one study was 22%Relapse rate in one study was 22%

Ortel S et al (2005) AJT 5, 2901-06Blaes A et al (2005) Cancer 104, 1661-7Choquet S et al (2006) Blood 107, 3053-7

Control of EBV replication by Control of EBV replication by adoptive Immunotherapyadoptive Immunotherapy

•• Expand EBV specific CD8 TExpand EBV specific CD8 T--cells (and CD4 Tcells (and CD4 T--cells) ex cells) ex vivo and then revivo and then re--infuse them into patients with high level infuse them into patients with high level EBV or patients with PTLDEBV or patients with PTLD

•• Pioneered in HSCT setting and now being applied in Pioneered in HSCT setting and now being applied in SOTSOT

•• Autologous CTLs Autologous CTLs reduce EBV load, expand in vivo and reduce EBV load, expand in vivo and result in regression of PTLDresult in regression of PTLD

•• Cells can be expanded from EBV Cells can be expanded from EBV seropositive seropositive recipients recipients but but seronegative seronegative recipients require cells expanded from recipients require cells expanded from allogeneic donorsallogeneic donors

CTL trial: Outcome at 6 monthsCTL trial: Outcome at 6 months• Complete response: 14/28 pts (50%)

• Tumour regressed• Graft function improved• EBV load decreased• 13 patients remain well and 1 relapsed

• Partial response: 3/28 pts (11%)• No response: 11/28 pts (39%)• Mortality

• 6 mo: 2/28 (7%) • 2 years: 6/28 (21%)

Haque Haque T et al, Transplantation 2001; T et al, Transplantation 2001; Haque Haque et al, Lancet 2002; et al, Lancet 2002; HaqueHaque et al et al (2007) Blood 110:1123(2007) Blood 110:1123--31.31.

Are we better prepared against EBV

•• Some progressSome progress•• Quantitative genome measurement available Quantitative genome measurement available

but predictive value uncertainbut predictive value uncertain•• AntiAnti--herpesviral herpesviral prophylaxis reduces prophylaxis reduces

incidence of EBV infection/PTLD incidence of EBV infection/PTLD •• Recent advances in therapyRecent advances in therapy

•• Rituximab Rituximab •• Adoptive TAdoptive T--cell therapycell therapy

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Thank YouThank You

There does not exist a category of There does not exist a category of science to which one can give the science to which one can give the name applied science. There are name applied science. There are

science and the applications of science and the applications of science, bound together as the fruit of science, bound together as the fruit of

the tree which bears itthe tree which bears it

Louis PasteurLouis Pasteur

post-transplant infection: are we better prepared to face

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