4
a
a
n
. a
Prophylaxis of cytom.egalovirus infect1.on with gancicl.ovir in a1.logeneic marrow transplantation a
a
Yau JC, Dimopoulos MA, Huan SD, Tarrand JJ, Spencer V, Spitzer G, Meneghetti CM, Wallerstein RO, Andersson B S, LeMaistre CF. Prophylaxis of cytomegalovirus infection with ganciclovir in allogeneic marrow transplantation. Eur J Haematol 1991: 47: 371-376. Abstract: Cytomegalovirus (CMV) infection is one of the most common causes of morbidity and mortality after allogeneic marrow transplantation. We studied 14 consecutive CMV-seropositive patients adding ganciclovir (2.5 mg/kg i.v. every 8 hours for 7 days prior to transplant and 6 mg/kg three times a week after neutrophils became > 0.5 x 109/1 and the patients were platelet transfusion-independent until d 70) to our previous prophylaxis regimen which consisted of intravenous immunoglobulin and acyclovir. The result was compared with 30 consecutive patients whom we studied with our previous regimen. The addition of ganciclovir did not cause any extra toxicities. The incidence of interstitial pneumonitis and cumulative probability of CMV excretion in the first 100 d post-transplantation was significantly reduced (p = 0.038 and p = 0.035 respectively). The result shows that addition of ganciclovir significantly decreased the incidence of CMV infection in the early post-transplantation period.
Introduction
Cytomegalovirus (CMV) infection represents an important obstacle to the success of allogeneic bone marrow transplantation. Patients who are seropositive for CMV before transplantation have an approximately 70% incidence of subsequent CMV infection (1,2). Viral reactivation appears to account for the high incidence of infection, although reinfection with new strains of CMV has been documented as well (1, 2). Manifestations of CMV infection can vary from asymptomatic excretion of the virus to the development of fatal interstitial pneumonitis. The latter complication occurs in approximately 20 % of patients who receive HLA-identical allogeneic marrow transplantation and has significant mortality (3). The median onset of CMV excretion was 52 d (3). The most successful treatment available today against clinically established CMV pneumonitis is the combination of intravenous immunoglobulin and ganciclovir (9-[ 2-Hydroxy- 1-1-l(Hydroxymethy1)Ethoxymethyl)Guanine), an antiviral agent with both in vitro and in vivo activity against CMV (4). The mechanism of action of the immunoglobulin component of this combination is not well understood, but it may serve as an immunomodulator rather than an antiviral agent (2). This combination has been
Jonathan C. Yau, Meletios A. Dimopoulos, Susan D. Hum, Jeffrey J. Tarrand, Verneeda Spencer, Gary Spitzer, Carole M. Meneghetti, Ralph 0. Wallerstein, Borje S. Andersson and C. Frederick LeMaistre Department of Hematology and Department of Laboratory Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
Key words: cytornegalovirus - ganciclovir prophylaxis - marrow transplantation Correspondence: Jonathan C. Yau, M.D., Ottawa Regional Cancer Centre, 190 Melrose Avenue, Ottawa, Ontario, Canada K1Y 4K7 Accepted for publication 28 June 199 1
associated with response rates of 52% to 70% in allogeneic marrow transplant patients with CMV pneumonitis (5, 6 , 7), but some studies have failed to confirm these results (8,9). Those patients who began therapy with milder disease appeared to respond better than those with severe respiratory failure (10). In view of the high incidence and mortality of CMV pneumonitis, particularly in CMV-seropositive recipients, several measures to prevent the infection were attempted. With prophylaxis, the aim is to prevent CMV reactivation until the reconstitution of graft immune function. Unfortunately, an effective prophylaxis has not yet been established. CMV immune plasma, immunoglobulin, vidarabine, human leukocyte interferon and low-dose acyclovir had not been shown to have any significant effect (1, 11, 12). Recently, high-dose prophylactic acyclovir was reported to decrease the CMV infection rate in CMV seropositive patients (13). The onset of CMV virus excretion was delayed by 22 d and the probability of CMVinfection was decreased from 0.87 to 0.70 (13). The use of an antiviral agent, such as ganciclovir and foscarnet, to suppress CMV reactivation throughout the major period of immune deficiency (approximately 3 to 4 months post-transplant) could be effective for the prevention of CMV disease (2). 371
Yau et al. Based on the hypothesis that the best available treatment for established CMV infection might be more effective when used for prophylaxis, we investigated the efficacy of ganciclovir for the prevention of CMV infection and disease in CMV-seropositive patients undergoing allogeneic marrow transplantation. Patients and methods
The study group consisted of 14 consecutive CMVseropositive patients with hematologic malignancies who underwent allogeneic marrow transplantation from HLA-A, B, C and DR matched siblings betwe& October 1989 and April 1990. The historical control group consisted of 30 consecutive CMVseropositivepatients who were treated between April 1988 and October 1989 in our Cancer Center prior to the initiation of the ganciclovir prophylaxis study. Patients who had positive culture for CMV before transplantation, history of prior CMV pneumonitis and those who were receiving a second allogeneic marrow transplant were not included in the analysis. The conditioning regimens are shown in Table 1. Total body irradiation in all our regimens was administered as 170 cGy twice a day, 6 h apart, for 3 d from a 20-MV linear accelerator. Informed consent was obtained from each patient before allogeneic bone marrow transplantation. The patients in the study group received ganciclovir at 2.5 mg/kg intravenously every 8 h for 7 d (d - 8 to d - 1). Intravenous immunoglobulin (Sandoz, Hanover, NJ or Travenol, Glendale, CA) was given at 500mg/kg every 2wk starting on d - 2 before until d + 250 after transplantation. Acyclovir Table 1. Patient characteristics Control Group Number of patients Median age (range) Sex (ma1e:femalel Donor CMV serology (p0sitive:negative) Diagnosis Acute myelogenous leukemia Acute lymphoblastic leukemia Chronic myelogenous leukemia Multiple myeloma Non-Hodgkin's Lymphoma Conditioning Regimens Cyclophosphamide, VP16, TBI Piperazinedione, TBI Busulfan, cyclophosphamide Melphalan, TBI Cyclophosphamide, VP16, BCNU Melphalan, busulfan Acute GVHD prophylaxis Methylprednisolone, cyclosporine, methotrexate Me~~ylprednisolone, CD5-immunotoxin Methylprednisolone, cyclosporine
372
30 32 (17-48) 16:14 19:ll 11
4 9
5 1
Study Group 14
33 (22-46) 8:6 9:5 3 3 6
0 2
20 4
2 3 0 1 24
14
5 1
0 0
was given intravenously at 5 mg/kg every 8 h, starting 1 d after the transplant and discontinued when the absolute granulocyte count was above 500 x lo6/ 1 and the platelet count was above 20 x 109/1without platelet transfusion. Ganciclovir was then restarted at 6 mg/kg i.v. three times a week until d 70. Acyclovir was then restarted at 200 mg orally twice a day for 1 year. The historical control group received intravenous acyclovir, starting on d 1, for 21 d then oral acyclovir 200 mg twice a day for 1 yr after transplantation and did not received any ganciclovir for prophylaxis. The historical control group received the identical intravenous immunoglobulin infusion regimen as those in the study group. All study and control patients were treated in laminar air flow units. All patients received sterile food, non-absorbable antibiotics and antifungal agents (gentamicin, vancomycin, and nystatin), and topical ointment (nystatin, vancomycin, polymyxin, and neomycin). Intravenous broad spectrum antibiotics were administered for fever greater than 38.4"C. Platelet transfusions were given for platelet counts less than 20 x 109/l. All the patients on the study group received the same prophylaxis for graft versus host disease, which consisted of methotrexate, cyclosporine and methylprednisolone as recently described (14). In both groups, urine and buffy coat of peripheral blood were cultured for CMV weekly until d 100 after transplantation. Bone marrow cultures for CMV were done monthly. Additional cultures were obtained if indicated clinically. Specimens for virus culture were inoculated into monolayer of human fibroblasts, which were maintained for 5 wk. Viruses were identified by early antigen expression or development of cytopathic effect. CMV antibody levels were not measured since all the patients were receiving intravenous immunoglobulin. CMV infection was diagnosed when cultures were positive. CMV interstitial pneumonitis was diagnosed when all of the following criteria were fulfilled: clinical and radiological evidence of interstitial pneumonitis, the presence of CMV immediate-early antigen or the isolation of the virus from bronchoalveolar lavage or lung tissue obtained by open lung biopsy and the absence of other pathogens that might cause interstitial pneumonitis. Only CMV infection occurring after the day of transplantation until d 100 was considered. The formal study period for both groups ended at 100 d after transplantation with follow-up thereafter continued according to the clinical condition of each patient. The patients in the study group who developed positive cultures for CMV were treated with ganciclovir 6 mg/kg per day i.v. with immunoglobulin weekly for 2 wk and then resumed ganciclovir prophylaxis protocol as mentioned above.
Ganciclovir prophylaxis of CMV infection The grading of toxicities and acute graft-versushost disease (GvHD) were done prospectively in all patients. The diagnosis and grading of acute GvHD were determined by skin biopsy and according to the Glucksberg criteria (15). Grading of mucositis, diarrhea, nausea and vomiting were determined according to the Eastern Cooperative Oncology Group scale (16). The incidence of acute GvHD and other event was compared by the chi-square test. Rate of engraftment and cumulative probability of CMV infection was performed according to the method of Kaplan and Meier (17). The survival results were analyzed as of December 1990.
Number of patients Patients with cytomegalovirus infection Median days to positive culture (range) Site of viral isolation Urine Buffy coat of peripheral blood Bone marrow Lung Interstitial pneumonitis CMV Other infections Idiopathic
Results
* p=0.042. ** p=0.038.
The patient characteristics are shown in Table 1. All the patients were treated for underlying hematologic malignancies. There was no difference in the percentage of CMV-seropositive donors in the two groups. There were no difference in the incidence and severity of mucositis, diarrhea, nausea and vomiting between the two groups. The post-transplantation results are shown in Table 2. There were no differences in the peak levels of total bilirubin, creatinine and time to hematopoietic recovery between the groups. Comparison of the late liver and renal toxicities were not made after d 14. The number of patients in the control group who developed greater than Grade I acute GvHD or interstitial pneumonitis requiring antibacterial and antifungal therapy prevented the comparison since none of the patients in the study group developed these complications. None of the patients in the study group developed greater than Grade I acute GvHD. Data pertinent to CMV infection until d 100 after transplantation are shown in Table 3. The most common site of CMV isolation in both groups was the urinary tract. The cumulative probability of CMV infection in the ganciclovir group after transplantation was significantly reduced (Fig. 1). The cumula-
Table 2. Post-transplantation data
Peak serum creatinine by Day 14 (range) umol/l Peak serum bilirubin by Day 14 (range) umol/l Median days to neutrophil > 0.5 X 109/1 (range) Median days to platelet > 2OX 10’11 (range) Acute GVHD Number evaluable patients Grade 0 Grade I Grade I1 Grade lll/lV
Control Group
Study Group
106 (44-362) 34 (13-284) 18 (9-49) 20 (11-78)
97 (44-565) 20 (1 1-189) 18 (11-271 20 (1 1-30)
29 16 7 3 3
13 8
5 0 0
Table 3. Cytomegalovirus infection in the first 100 d post transplantation Control Group
Study Group
30 15 49 ( 16-88)
14 3 82 (67-95)’
10 6 1
3 1 0 0
5 10 5 1 4
O** 0 0 0
tive probability of CMV infection was 2 1% in the patients of the study group versus 50% in the control group. The patients who received ganciclovir prophylaxis developed the CMV infection later than the patients of the control group (median 82 d versus 49 d p = 0.042). None of the patients who received ganciclovir prophylaxis developed interstitial pneumonitis during the first 100 d post-transplant. In contrast, 10 of the control group developed interstitial pneumonia (p = 0.038). Five of these developed interstitial pneumonia secondary to CMV. In 4 of these 5 patients the CMV pneumonitis was fatal in spite of intensive treatment with ganciclovir and intravenous immunoglobulin. One patient recovered and remains alive with no evidence of pneumonitis 59 months posttransplantation. Five patients in the control group developed non-CMV interstitial pneumonitis. Candida albicans was isolated from the bronchoalveolar lavage in one of these patients. The other 4 patients were considered to have idiopathic interstitial pneumonitis based on open lung biopsy specimen that showed interstitial pulmonary fibrosis and absence of pathogens, All these 4 patients died of respiratory failure. None of the ganciclovir prophylaxis patients had developed interstitial pneumonitis at the time of last follow-up. There were 13 deaths in the control group versus 2 in the ganciclovir group. In the control group, 8 patients died secondary to interstitial pneumonitis as mentioned above and 5 patients died from other causes (2 leukemia relapses, 1 intracranial bleeding, 1 liver venoocclusive disease, 1 complication of grand mal seizure). In the ganciclovir group, 1 patient died on d 7 of acute pulmonary hemorrhage and had had a normal chest x-ray 1 d prior to his death, and 1 died on d 215 from systemic candidiasis. 313
Yau et al.
Proportion
0.8
0.6
1
P=0.035
1
,....._________.. .....,
0.4
r..,
,......, ...._........ ....m
0.2
0 0
10
20
30
40
50
60
70
80
90
100
Days Fig. 1. Cumulative probability of cytomegalovirus infection after transplantation in the study group (solid line) and the historical control group (broken line).
Discussion
CMV pneumonitis remain one of the most common causes of death in the early post-transplantation period among CMV-seropositive patients, in spite of the currently available treatment (2, 10). The patients who recovered from CMV pneumonitis appeared to be more susceptible to several bacterial and fungal infections (lo). Prevention of CMV reactivation or infection is a rational approach. Although CMV infection can be effectively prevented in the seronegative patients with the use of only seronegative blood products, effective prophylaxis was not available for the CMV seropositive patients (1,2). Our preliminary results show that our prophylaxis regimen which includes ganciclovir, acyclovir and intravenous immunoglobulin can be administered without major side-effects. This combination significantly delayed the median onset of CMV viral excretion by 33 d (p = 0.042). The probability of early CMV infection was also significantly decreased (p = 0.035). Of particular interest is the absence of interstitial pneumonitis post-transplantation in the study group. A major concern in the use of ganciclovir is the neutropenia that it can induce, which is frequent in the patients with the acquired immunodeficiency syndrome (18). We have shown that the administration of ganciclovir before the transplantation and 374
after evidence of engraftment did not impair the completion of hematopoietic reconstitution. This is in agreement with experimental data (19). Furthermore, there was no potentiation of cyclosporine toxicity as shown by the lack of changes in the peak total bilirubin and creatinine during the first 2 wk after transplantation. This can potentially be a significant problem with the use of foscarnet as a prophylactic agent since significant nephrotoxicity has been reported with the agent (20). The cumulative probability of CMV infection within the first 100 d after transplantation was reduced from 0.50 at a median of 49 d among control group to 0.21 at a median of 82 d in the study group. The incidence of CMV infection and particularly of CMV pneumonitis was probably reduced because CMV infection was delayed until a period of better immune reconstitution for CMV-specific immune responses. Early treatment of CMV pneumonitis with ganciclovir and immunoglobulin is more effective than treatment of advanced disease (10). The early institution of ganciclovir as soon as CMV excretion was documented in the first 100d posttransplantation may also be effective in the prevention of CMV pneumonitis. Our regimen significantly decreased the overall incidence of interstitial pneumonitis, suggesting that some of the idiopathic pneumonitis may well be secondary to undiagnosed CMV infection and preventing CMV infection may ini-
Ganciclovir prophylaxis of CMV infection prove the overall survival. The same observation was made in the acyclovir study (13). 2 of the 3 patients who had CMV excretion only shed CMV after discontinuation of ganciclovir. The incomplete protection of these 2 patients was probably due to the limited period of administration of ganciclovir which was only given up to 70 d posttransplantation. The patient who had CMV excretion at d 67 stopped shedding CMV after the ganciclovir dose was increased to daily injections, suggesting that the three-times-a-week dosage may not be adequate for some patients. Perhaps the prophylaxis with ganciclovir should be given more frequently and be continued for a more extended period of time until the CMV-specific immune responses were further improved for a more complete protection against CMV reactivation or infection. This may be feasible in view of the absence of significant myelotoxicity. However, more frequent or longer administration of ganciclovir may potentially cause significant toxicities. The efficacy of a longer and more intense dosing of ganciclovir is currently being tested in a randomized trial in another Center (21). Other methods for prophylaxis of CMV infection such as monoclonal antibodies against CMV and the transfer of adoptive immunotherapy with cloned CMVreactive T cells from the marrow donor to the patient after transplantation are also being investigated (2722). The effect of ganciclovir prophylaxis on acute GvHD and long-term survival is not clear. In a murine model CMV lowered the threshold for the GvHD but the exact mechanism was unclear (23). It has been shown that there is a immunologic crossreactivity between HLA-DR beta chain and immediate early antigen of human CMV (24). A glycoprotein homologous to HLA class I antigens has been found on cells infected with CMV (25). CMV infection of cell lines has also been shown to upregulate the expression of HLA class I antigens (26). It is possible that acute GvHD may be exacerbated by CMV infection through a T-cell response to the overt expression of HLA class I antigen or similar glycoprotein. Prevention of CMV infection may therefore decrease the incidence and severity of GvHD. The incidence and severity of acute GvHD in the study group appear to be lower than the control group but did not reach statistical significance in this small group. All but 6 patients in the control group received a combination of methylprednisolone, methotrexate and cyclosporine for GvHD prophylaxis. Only 1 of these 6 patients developed CMV pneumonitis. It is therefore unlikely that the GvHD prophylaxis alone could have influenced the frequency of CMV pneumonitis. In conclusion, the results show that prophylaxis with ganciclovir at the dose and duration given in
this study did not increase toxicities and appeared to be effective in delaying and reducing the incidence of CMV infection after allogeneic marrow transplantation. The beneficial effect on the overall survival after allogeneic transplantation needs to be proven in a randomized trial. References RA, MEYERS JD. Prophylaxis of cytomegalovirus 1. BOWDEN infection. Sem Hematol 1990: 27 (Suppl 1): 17-21. JD. Prevention of cytomegalovirus infection after 2. MEYERS marrow transplantation. Rev Infect Dis 1989: 11 (Suppl 7): S 1 6 9 1 4 1705. 3. WEINERRS, BORTINMM, GALERP, et al. Interstitial pneumonitis after bone marrow transplantation: assessment of risk factors. Ann Intern Med 1986: 104: 168-175. 4. MATTHEWS T, BOEHMER. Antiviral activity and mechanism of action of Ganciclovir. (Review.) Rev Infect Dis 1988: 10 (SUPPI3): S4904494. RA, DANDLIKER PS, LILLEBYKF, 5. REEDEC, BOWDEN MEYERS JD. Treatment of cytomegalovirus pneumonia with Ganciclovir and intravenous cytomegalovirus immunoglobulin in patients with bone marrow transplants. Ann Intern Med 1988: 109: 783-788. D, CUNNINGHAM I, JULES-ELYSEE K, et al. Cy6. EMANUEL
tomegalovirus pneumonia after bone marrow transplantation successfully treated with the combination of ganciclovir and high dose intravenous immune globulin. Ann Intern Med 1988: 109: 777-796. GM, KOVACSA, ZAIAJA, etal. Ganciclovir/ 7. SCHMIDT
immunoglobulin combination therapy for the treatment of human cytomegalovirus-associated interstitial pneumonia in bone marrow allograft recipients. Transplantation 1988: 46: 905-907. AW, DE WEGER 8. VERDONCKLF, DE GASTGC, DEKKER
RA, SCHUURMAN HJ, ROZENBERG-ARSKA M.' Treatment of cytomegalovirus pneumonia after bone marrow transplantation with cytomegalovirus immunoglobulin combined with ganciclovir. Bone Marrow Transplant 1989: 4: 187-189. WE, TILGH, NIEDERWIESER D, et al. Ganci9. AULITZSKY clovir and hyperimmunoglobulin for treating cytomegalovirus infection in bone marrow transplant recipients. J Infect Dis 1988: 158: 488-489. D. Treatment of cytomegalovirus disease. Sem 10. EMANUEL Hematol 1990: 27 (Suppl 1): 22-27. 0, PHILSTEDT P, VOLINL, et al. Failure to pre11. RINGDEN
vent cytomegalovirus infection by cytomegalovirus hyperimmune plasma: a randomized trial by the Nordic Bone Marrow Transplantation Group. Bone Marrow Transplant 1987: 2: 299-305. JP. Evaluation of therapy for cytomegalovirus 12. VERHEYDEN infection. Rev Infect Dis 1988: 10 (Suppl 3): S4774489. 13. MEYERJD, REEDEC, SHEPPDH, et al. Acyclovir for pre-
vention of cytomegalovirus infection and disease after allogeneic marrow transplantation. N Engl J Med 1988: 318: 70-75. CF, ZAGARS GK, et al. Methylpred14. YAUJC, LEMAISTRE
nisolone, cyclosporine and methotrexate for prophylaxis of acute graft-versus-host disease. Bone Marrow Transplant 1990: 5 : 269-272. H, STORBR, FEFERA, et al. Clinical mani15. GLUCKSBERG festations of graft-versus-host disease in human recipients of marrow from HLA matched sibling donors. Transplantation 1974: 18: 295-304. D, et al. Toxicity and re16, OKENM, CREECHR, TORMEY sponse criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982: 5: 649-655.
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Yau et al. 17. KAPLANEL, MEIER R. Non-parametric estimation from incompleteobservations. J Am Stat Assoc 1958: 53: 457-481. 18. H o WC, WINSTONDJ, CHAMPLINRE. Tolerance and ef-
ficacy of Gancyclovir in the treatment of cytomegalovirus infections in immunosuppressed patients. Transplant Proc 1989: 21: 3103-3106. 19. APPELBAUMFR, MEYERSJD, DEEG HJ, GRAHAM T, SCHUENING F, STORBR. Toxicity trial of prophylactic 9[2-Hydroxy-1-(Hydroxymethyl)Ethoxymethyl]Guanine
(Ganciclovir) after marrow transplantation in dogs. Antimicrob Agent Chemother 1988: 32: 271-273. B, ASCHANJ, SUNDBERG B. Fo20. RINGDEN0, LONNQVIST scarnet prophylaxis in marrow transplant recipients. (Letter.) Bone Marrow Transplant 1989: 4: 713. RE. Current approaches 21. WINSTONDJ,H o WG, CHAMPLIN to management of infections in bone marrow transplants. Eur J Cancer Clin Oncol 1989: 25 (Suppl2): S25-S35. 22. EMANUEL D, PEPPARD J, CHEMINIJ, HAMMERLING U, O’REILLYR. The diagnostic, prophylactic and therapeutic
376
uses of monoclonal antibodies to human cytomegalovirus. Transplant Proc 1987: 19 (Suppl 7): 132-137. JD, WEATHERLY BR, LANGP, SHEARER 23. VIACS, SHANLEY GM. Altered threshold for the induction of graft-versus-host immunodeficiency following murine cytomegalovirus infection. Host and donor contributions. Transplantation 1988: 46: 298-302. 24. FUJINAMI RS, NELSONJA, WALKERL, OLDSTONEMB.
Sequence homology and immunologic cross-reactivity of human cytomegalovirus with HLA-DR beta chain: a means for graft rejection and immunosuppression. J Virol 1988: 62: 100-105. 25. BECKS, BARRELLBG. Human cytomegalovirus encodes a
glycoprotein homologous to MHC class-I antigens. Nature 1988: 331: 269-212. 26. GRUNDY JE, AYLESHM, MCKEATINGJA, et al. Enhance-
ment of class I HLA antigen expression by cytomegalovirus: role in ampliication of virus infection. J Med Virol 1988: 25: 483-495.
a
a
n
. a
Prophylaxis of cytom.egalovirus infect1.on with gancicl.ovir in a1.logeneic marrow transplantation a
a
Yau JC, Dimopoulos MA, Huan SD, Tarrand JJ, Spencer V, Spitzer G, Meneghetti CM, Wallerstein RO, Andersson B S, LeMaistre CF. Prophylaxis of cytomegalovirus infection with ganciclovir in allogeneic marrow transplantation. Eur J Haematol 1991: 47: 371-376. Abstract: Cytomegalovirus (CMV) infection is one of the most common causes of morbidity and mortality after allogeneic marrow transplantation. We studied 14 consecutive CMV-seropositive patients adding ganciclovir (2.5 mg/kg i.v. every 8 hours for 7 days prior to transplant and 6 mg/kg three times a week after neutrophils became > 0.5 x 109/1 and the patients were platelet transfusion-independent until d 70) to our previous prophylaxis regimen which consisted of intravenous immunoglobulin and acyclovir. The result was compared with 30 consecutive patients whom we studied with our previous regimen. The addition of ganciclovir did not cause any extra toxicities. The incidence of interstitial pneumonitis and cumulative probability of CMV excretion in the first 100 d post-transplantation was significantly reduced (p = 0.038 and p = 0.035 respectively). The result shows that addition of ganciclovir significantly decreased the incidence of CMV infection in the early post-transplantation period.
Introduction
Cytomegalovirus (CMV) infection represents an important obstacle to the success of allogeneic bone marrow transplantation. Patients who are seropositive for CMV before transplantation have an approximately 70% incidence of subsequent CMV infection (1,2). Viral reactivation appears to account for the high incidence of infection, although reinfection with new strains of CMV has been documented as well (1, 2). Manifestations of CMV infection can vary from asymptomatic excretion of the virus to the development of fatal interstitial pneumonitis. The latter complication occurs in approximately 20 % of patients who receive HLA-identical allogeneic marrow transplantation and has significant mortality (3). The median onset of CMV excretion was 52 d (3). The most successful treatment available today against clinically established CMV pneumonitis is the combination of intravenous immunoglobulin and ganciclovir (9-[ 2-Hydroxy- 1-1-l(Hydroxymethy1)Ethoxymethyl)Guanine), an antiviral agent with both in vitro and in vivo activity against CMV (4). The mechanism of action of the immunoglobulin component of this combination is not well understood, but it may serve as an immunomodulator rather than an antiviral agent (2). This combination has been
Jonathan C. Yau, Meletios A. Dimopoulos, Susan D. Hum, Jeffrey J. Tarrand, Verneeda Spencer, Gary Spitzer, Carole M. Meneghetti, Ralph 0. Wallerstein, Borje S. Andersson and C. Frederick LeMaistre Department of Hematology and Department of Laboratory Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
Key words: cytornegalovirus - ganciclovir prophylaxis - marrow transplantation Correspondence: Jonathan C. Yau, M.D., Ottawa Regional Cancer Centre, 190 Melrose Avenue, Ottawa, Ontario, Canada K1Y 4K7 Accepted for publication 28 June 199 1
associated with response rates of 52% to 70% in allogeneic marrow transplant patients with CMV pneumonitis (5, 6 , 7), but some studies have failed to confirm these results (8,9). Those patients who began therapy with milder disease appeared to respond better than those with severe respiratory failure (10). In view of the high incidence and mortality of CMV pneumonitis, particularly in CMV-seropositive recipients, several measures to prevent the infection were attempted. With prophylaxis, the aim is to prevent CMV reactivation until the reconstitution of graft immune function. Unfortunately, an effective prophylaxis has not yet been established. CMV immune plasma, immunoglobulin, vidarabine, human leukocyte interferon and low-dose acyclovir had not been shown to have any significant effect (1, 11, 12). Recently, high-dose prophylactic acyclovir was reported to decrease the CMV infection rate in CMV seropositive patients (13). The onset of CMV virus excretion was delayed by 22 d and the probability of CMVinfection was decreased from 0.87 to 0.70 (13). The use of an antiviral agent, such as ganciclovir and foscarnet, to suppress CMV reactivation throughout the major period of immune deficiency (approximately 3 to 4 months post-transplant) could be effective for the prevention of CMV disease (2). 371
Yau et al. Based on the hypothesis that the best available treatment for established CMV infection might be more effective when used for prophylaxis, we investigated the efficacy of ganciclovir for the prevention of CMV infection and disease in CMV-seropositive patients undergoing allogeneic marrow transplantation. Patients and methods
The study group consisted of 14 consecutive CMVseropositive patients with hematologic malignancies who underwent allogeneic marrow transplantation from HLA-A, B, C and DR matched siblings betwe& October 1989 and April 1990. The historical control group consisted of 30 consecutive CMVseropositivepatients who were treated between April 1988 and October 1989 in our Cancer Center prior to the initiation of the ganciclovir prophylaxis study. Patients who had positive culture for CMV before transplantation, history of prior CMV pneumonitis and those who were receiving a second allogeneic marrow transplant were not included in the analysis. The conditioning regimens are shown in Table 1. Total body irradiation in all our regimens was administered as 170 cGy twice a day, 6 h apart, for 3 d from a 20-MV linear accelerator. Informed consent was obtained from each patient before allogeneic bone marrow transplantation. The patients in the study group received ganciclovir at 2.5 mg/kg intravenously every 8 h for 7 d (d - 8 to d - 1). Intravenous immunoglobulin (Sandoz, Hanover, NJ or Travenol, Glendale, CA) was given at 500mg/kg every 2wk starting on d - 2 before until d + 250 after transplantation. Acyclovir Table 1. Patient characteristics Control Group Number of patients Median age (range) Sex (ma1e:femalel Donor CMV serology (p0sitive:negative) Diagnosis Acute myelogenous leukemia Acute lymphoblastic leukemia Chronic myelogenous leukemia Multiple myeloma Non-Hodgkin's Lymphoma Conditioning Regimens Cyclophosphamide, VP16, TBI Piperazinedione, TBI Busulfan, cyclophosphamide Melphalan, TBI Cyclophosphamide, VP16, BCNU Melphalan, busulfan Acute GVHD prophylaxis Methylprednisolone, cyclosporine, methotrexate Me~~ylprednisolone, CD5-immunotoxin Methylprednisolone, cyclosporine
372
30 32 (17-48) 16:14 19:ll 11
4 9
5 1
Study Group 14
33 (22-46) 8:6 9:5 3 3 6
0 2
20 4
2 3 0 1 24
14
5 1
0 0
was given intravenously at 5 mg/kg every 8 h, starting 1 d after the transplant and discontinued when the absolute granulocyte count was above 500 x lo6/ 1 and the platelet count was above 20 x 109/1without platelet transfusion. Ganciclovir was then restarted at 6 mg/kg i.v. three times a week until d 70. Acyclovir was then restarted at 200 mg orally twice a day for 1 year. The historical control group received intravenous acyclovir, starting on d 1, for 21 d then oral acyclovir 200 mg twice a day for 1 yr after transplantation and did not received any ganciclovir for prophylaxis. The historical control group received the identical intravenous immunoglobulin infusion regimen as those in the study group. All study and control patients were treated in laminar air flow units. All patients received sterile food, non-absorbable antibiotics and antifungal agents (gentamicin, vancomycin, and nystatin), and topical ointment (nystatin, vancomycin, polymyxin, and neomycin). Intravenous broad spectrum antibiotics were administered for fever greater than 38.4"C. Platelet transfusions were given for platelet counts less than 20 x 109/l. All the patients on the study group received the same prophylaxis for graft versus host disease, which consisted of methotrexate, cyclosporine and methylprednisolone as recently described (14). In both groups, urine and buffy coat of peripheral blood were cultured for CMV weekly until d 100 after transplantation. Bone marrow cultures for CMV were done monthly. Additional cultures were obtained if indicated clinically. Specimens for virus culture were inoculated into monolayer of human fibroblasts, which were maintained for 5 wk. Viruses were identified by early antigen expression or development of cytopathic effect. CMV antibody levels were not measured since all the patients were receiving intravenous immunoglobulin. CMV infection was diagnosed when cultures were positive. CMV interstitial pneumonitis was diagnosed when all of the following criteria were fulfilled: clinical and radiological evidence of interstitial pneumonitis, the presence of CMV immediate-early antigen or the isolation of the virus from bronchoalveolar lavage or lung tissue obtained by open lung biopsy and the absence of other pathogens that might cause interstitial pneumonitis. Only CMV infection occurring after the day of transplantation until d 100 was considered. The formal study period for both groups ended at 100 d after transplantation with follow-up thereafter continued according to the clinical condition of each patient. The patients in the study group who developed positive cultures for CMV were treated with ganciclovir 6 mg/kg per day i.v. with immunoglobulin weekly for 2 wk and then resumed ganciclovir prophylaxis protocol as mentioned above.
Ganciclovir prophylaxis of CMV infection The grading of toxicities and acute graft-versushost disease (GvHD) were done prospectively in all patients. The diagnosis and grading of acute GvHD were determined by skin biopsy and according to the Glucksberg criteria (15). Grading of mucositis, diarrhea, nausea and vomiting were determined according to the Eastern Cooperative Oncology Group scale (16). The incidence of acute GvHD and other event was compared by the chi-square test. Rate of engraftment and cumulative probability of CMV infection was performed according to the method of Kaplan and Meier (17). The survival results were analyzed as of December 1990.
Number of patients Patients with cytomegalovirus infection Median days to positive culture (range) Site of viral isolation Urine Buffy coat of peripheral blood Bone marrow Lung Interstitial pneumonitis CMV Other infections Idiopathic
Results
* p=0.042. ** p=0.038.
The patient characteristics are shown in Table 1. All the patients were treated for underlying hematologic malignancies. There was no difference in the percentage of CMV-seropositive donors in the two groups. There were no difference in the incidence and severity of mucositis, diarrhea, nausea and vomiting between the two groups. The post-transplantation results are shown in Table 2. There were no differences in the peak levels of total bilirubin, creatinine and time to hematopoietic recovery between the groups. Comparison of the late liver and renal toxicities were not made after d 14. The number of patients in the control group who developed greater than Grade I acute GvHD or interstitial pneumonitis requiring antibacterial and antifungal therapy prevented the comparison since none of the patients in the study group developed these complications. None of the patients in the study group developed greater than Grade I acute GvHD. Data pertinent to CMV infection until d 100 after transplantation are shown in Table 3. The most common site of CMV isolation in both groups was the urinary tract. The cumulative probability of CMV infection in the ganciclovir group after transplantation was significantly reduced (Fig. 1). The cumula-
Table 2. Post-transplantation data
Peak serum creatinine by Day 14 (range) umol/l Peak serum bilirubin by Day 14 (range) umol/l Median days to neutrophil > 0.5 X 109/1 (range) Median days to platelet > 2OX 10’11 (range) Acute GVHD Number evaluable patients Grade 0 Grade I Grade I1 Grade lll/lV
Control Group
Study Group
106 (44-362) 34 (13-284) 18 (9-49) 20 (11-78)
97 (44-565) 20 (1 1-189) 18 (11-271 20 (1 1-30)
29 16 7 3 3
13 8
5 0 0
Table 3. Cytomegalovirus infection in the first 100 d post transplantation Control Group
Study Group
30 15 49 ( 16-88)
14 3 82 (67-95)’
10 6 1
3 1 0 0
5 10 5 1 4
O** 0 0 0
tive probability of CMV infection was 2 1% in the patients of the study group versus 50% in the control group. The patients who received ganciclovir prophylaxis developed the CMV infection later than the patients of the control group (median 82 d versus 49 d p = 0.042). None of the patients who received ganciclovir prophylaxis developed interstitial pneumonitis during the first 100 d post-transplant. In contrast, 10 of the control group developed interstitial pneumonia (p = 0.038). Five of these developed interstitial pneumonia secondary to CMV. In 4 of these 5 patients the CMV pneumonitis was fatal in spite of intensive treatment with ganciclovir and intravenous immunoglobulin. One patient recovered and remains alive with no evidence of pneumonitis 59 months posttransplantation. Five patients in the control group developed non-CMV interstitial pneumonitis. Candida albicans was isolated from the bronchoalveolar lavage in one of these patients. The other 4 patients were considered to have idiopathic interstitial pneumonitis based on open lung biopsy specimen that showed interstitial pulmonary fibrosis and absence of pathogens, All these 4 patients died of respiratory failure. None of the ganciclovir prophylaxis patients had developed interstitial pneumonitis at the time of last follow-up. There were 13 deaths in the control group versus 2 in the ganciclovir group. In the control group, 8 patients died secondary to interstitial pneumonitis as mentioned above and 5 patients died from other causes (2 leukemia relapses, 1 intracranial bleeding, 1 liver venoocclusive disease, 1 complication of grand mal seizure). In the ganciclovir group, 1 patient died on d 7 of acute pulmonary hemorrhage and had had a normal chest x-ray 1 d prior to his death, and 1 died on d 215 from systemic candidiasis. 313
Yau et al.
Proportion
0.8
0.6
1
P=0.035
1
,....._________.. .....,
0.4
r..,
,......, ...._........ ....m
0.2
0 0
10
20
30
40
50
60
70
80
90
100
Days Fig. 1. Cumulative probability of cytomegalovirus infection after transplantation in the study group (solid line) and the historical control group (broken line).
Discussion
CMV pneumonitis remain one of the most common causes of death in the early post-transplantation period among CMV-seropositive patients, in spite of the currently available treatment (2, 10). The patients who recovered from CMV pneumonitis appeared to be more susceptible to several bacterial and fungal infections (lo). Prevention of CMV reactivation or infection is a rational approach. Although CMV infection can be effectively prevented in the seronegative patients with the use of only seronegative blood products, effective prophylaxis was not available for the CMV seropositive patients (1,2). Our preliminary results show that our prophylaxis regimen which includes ganciclovir, acyclovir and intravenous immunoglobulin can be administered without major side-effects. This combination significantly delayed the median onset of CMV viral excretion by 33 d (p = 0.042). The probability of early CMV infection was also significantly decreased (p = 0.035). Of particular interest is the absence of interstitial pneumonitis post-transplantation in the study group. A major concern in the use of ganciclovir is the neutropenia that it can induce, which is frequent in the patients with the acquired immunodeficiency syndrome (18). We have shown that the administration of ganciclovir before the transplantation and 374
after evidence of engraftment did not impair the completion of hematopoietic reconstitution. This is in agreement with experimental data (19). Furthermore, there was no potentiation of cyclosporine toxicity as shown by the lack of changes in the peak total bilirubin and creatinine during the first 2 wk after transplantation. This can potentially be a significant problem with the use of foscarnet as a prophylactic agent since significant nephrotoxicity has been reported with the agent (20). The cumulative probability of CMV infection within the first 100 d after transplantation was reduced from 0.50 at a median of 49 d among control group to 0.21 at a median of 82 d in the study group. The incidence of CMV infection and particularly of CMV pneumonitis was probably reduced because CMV infection was delayed until a period of better immune reconstitution for CMV-specific immune responses. Early treatment of CMV pneumonitis with ganciclovir and immunoglobulin is more effective than treatment of advanced disease (10). The early institution of ganciclovir as soon as CMV excretion was documented in the first 100d posttransplantation may also be effective in the prevention of CMV pneumonitis. Our regimen significantly decreased the overall incidence of interstitial pneumonitis, suggesting that some of the idiopathic pneumonitis may well be secondary to undiagnosed CMV infection and preventing CMV infection may ini-
Ganciclovir prophylaxis of CMV infection prove the overall survival. The same observation was made in the acyclovir study (13). 2 of the 3 patients who had CMV excretion only shed CMV after discontinuation of ganciclovir. The incomplete protection of these 2 patients was probably due to the limited period of administration of ganciclovir which was only given up to 70 d posttransplantation. The patient who had CMV excretion at d 67 stopped shedding CMV after the ganciclovir dose was increased to daily injections, suggesting that the three-times-a-week dosage may not be adequate for some patients. Perhaps the prophylaxis with ganciclovir should be given more frequently and be continued for a more extended period of time until the CMV-specific immune responses were further improved for a more complete protection against CMV reactivation or infection. This may be feasible in view of the absence of significant myelotoxicity. However, more frequent or longer administration of ganciclovir may potentially cause significant toxicities. The efficacy of a longer and more intense dosing of ganciclovir is currently being tested in a randomized trial in another Center (21). Other methods for prophylaxis of CMV infection such as monoclonal antibodies against CMV and the transfer of adoptive immunotherapy with cloned CMVreactive T cells from the marrow donor to the patient after transplantation are also being investigated (2722). The effect of ganciclovir prophylaxis on acute GvHD and long-term survival is not clear. In a murine model CMV lowered the threshold for the GvHD but the exact mechanism was unclear (23). It has been shown that there is a immunologic crossreactivity between HLA-DR beta chain and immediate early antigen of human CMV (24). A glycoprotein homologous to HLA class I antigens has been found on cells infected with CMV (25). CMV infection of cell lines has also been shown to upregulate the expression of HLA class I antigens (26). It is possible that acute GvHD may be exacerbated by CMV infection through a T-cell response to the overt expression of HLA class I antigen or similar glycoprotein. Prevention of CMV infection may therefore decrease the incidence and severity of GvHD. The incidence and severity of acute GvHD in the study group appear to be lower than the control group but did not reach statistical significance in this small group. All but 6 patients in the control group received a combination of methylprednisolone, methotrexate and cyclosporine for GvHD prophylaxis. Only 1 of these 6 patients developed CMV pneumonitis. It is therefore unlikely that the GvHD prophylaxis alone could have influenced the frequency of CMV pneumonitis. In conclusion, the results show that prophylaxis with ganciclovir at the dose and duration given in
this study did not increase toxicities and appeared to be effective in delaying and reducing the incidence of CMV infection after allogeneic marrow transplantation. The beneficial effect on the overall survival after allogeneic transplantation needs to be proven in a randomized trial. References RA, MEYERS JD. Prophylaxis of cytomegalovirus 1. BOWDEN infection. Sem Hematol 1990: 27 (Suppl 1): 17-21. JD. Prevention of cytomegalovirus infection after 2. MEYERS marrow transplantation. Rev Infect Dis 1989: 11 (Suppl 7): S 1 6 9 1 4 1705. 3. WEINERRS, BORTINMM, GALERP, et al. Interstitial pneumonitis after bone marrow transplantation: assessment of risk factors. Ann Intern Med 1986: 104: 168-175. 4. MATTHEWS T, BOEHMER. Antiviral activity and mechanism of action of Ganciclovir. (Review.) Rev Infect Dis 1988: 10 (SUPPI3): S4904494. RA, DANDLIKER PS, LILLEBYKF, 5. REEDEC, BOWDEN MEYERS JD. Treatment of cytomegalovirus pneumonia with Ganciclovir and intravenous cytomegalovirus immunoglobulin in patients with bone marrow transplants. Ann Intern Med 1988: 109: 783-788. D, CUNNINGHAM I, JULES-ELYSEE K, et al. Cy6. EMANUEL
tomegalovirus pneumonia after bone marrow transplantation successfully treated with the combination of ganciclovir and high dose intravenous immune globulin. Ann Intern Med 1988: 109: 777-796. GM, KOVACSA, ZAIAJA, etal. Ganciclovir/ 7. SCHMIDT
immunoglobulin combination therapy for the treatment of human cytomegalovirus-associated interstitial pneumonia in bone marrow allograft recipients. Transplantation 1988: 46: 905-907. AW, DE WEGER 8. VERDONCKLF, DE GASTGC, DEKKER
RA, SCHUURMAN HJ, ROZENBERG-ARSKA M.' Treatment of cytomegalovirus pneumonia after bone marrow transplantation with cytomegalovirus immunoglobulin combined with ganciclovir. Bone Marrow Transplant 1989: 4: 187-189. WE, TILGH, NIEDERWIESER D, et al. Ganci9. AULITZSKY clovir and hyperimmunoglobulin for treating cytomegalovirus infection in bone marrow transplant recipients. J Infect Dis 1988: 158: 488-489. D. Treatment of cytomegalovirus disease. Sem 10. EMANUEL Hematol 1990: 27 (Suppl 1): 22-27. 0, PHILSTEDT P, VOLINL, et al. Failure to pre11. RINGDEN
vent cytomegalovirus infection by cytomegalovirus hyperimmune plasma: a randomized trial by the Nordic Bone Marrow Transplantation Group. Bone Marrow Transplant 1987: 2: 299-305. JP. Evaluation of therapy for cytomegalovirus 12. VERHEYDEN infection. Rev Infect Dis 1988: 10 (Suppl 3): S4774489. 13. MEYERJD, REEDEC, SHEPPDH, et al. Acyclovir for pre-
vention of cytomegalovirus infection and disease after allogeneic marrow transplantation. N Engl J Med 1988: 318: 70-75. CF, ZAGARS GK, et al. Methylpred14. YAUJC, LEMAISTRE
nisolone, cyclosporine and methotrexate for prophylaxis of acute graft-versus-host disease. Bone Marrow Transplant 1990: 5 : 269-272. H, STORBR, FEFERA, et al. Clinical mani15. GLUCKSBERG festations of graft-versus-host disease in human recipients of marrow from HLA matched sibling donors. Transplantation 1974: 18: 295-304. D, et al. Toxicity and re16, OKENM, CREECHR, TORMEY sponse criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982: 5: 649-655.
375
Yau et al. 17. KAPLANEL, MEIER R. Non-parametric estimation from incompleteobservations. J Am Stat Assoc 1958: 53: 457-481. 18. H o WC, WINSTONDJ, CHAMPLINRE. Tolerance and ef-
ficacy of Gancyclovir in the treatment of cytomegalovirus infections in immunosuppressed patients. Transplant Proc 1989: 21: 3103-3106. 19. APPELBAUMFR, MEYERSJD, DEEG HJ, GRAHAM T, SCHUENING F, STORBR. Toxicity trial of prophylactic 9[2-Hydroxy-1-(Hydroxymethyl)Ethoxymethyl]Guanine
(Ganciclovir) after marrow transplantation in dogs. Antimicrob Agent Chemother 1988: 32: 271-273. B, ASCHANJ, SUNDBERG B. Fo20. RINGDEN0, LONNQVIST scarnet prophylaxis in marrow transplant recipients. (Letter.) Bone Marrow Transplant 1989: 4: 713. RE. Current approaches 21. WINSTONDJ,H o WG, CHAMPLIN to management of infections in bone marrow transplants. Eur J Cancer Clin Oncol 1989: 25 (Suppl2): S25-S35. 22. EMANUEL D, PEPPARD J, CHEMINIJ, HAMMERLING U, O’REILLYR. The diagnostic, prophylactic and therapeutic
376
uses of monoclonal antibodies to human cytomegalovirus. Transplant Proc 1987: 19 (Suppl 7): 132-137. JD, WEATHERLY BR, LANGP, SHEARER 23. VIACS, SHANLEY GM. Altered threshold for the induction of graft-versus-host immunodeficiency following murine cytomegalovirus infection. Host and donor contributions. Transplantation 1988: 46: 298-302. 24. FUJINAMI RS, NELSONJA, WALKERL, OLDSTONEMB.
Sequence homology and immunologic cross-reactivity of human cytomegalovirus with HLA-DR beta chain: a means for graft rejection and immunosuppression. J Virol 1988: 62: 100-105. 25. BECKS, BARRELLBG. Human cytomegalovirus encodes a
glycoprotein homologous to MHC class-I antigens. Nature 1988: 331: 269-212. 26. GRUNDY JE, AYLESHM, MCKEATINGJA, et al. Enhance-
ment of class I HLA antigen expression by cytomegalovirus: role in ampliication of virus infection. J Med Virol 1988: 25: 483-495.
