© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Transplant Infectious Disease, ISSN 1398-2273
Risk factors for hemorrhagic cystitis in pediatric allogeneic hematopoietic stem cell transplant recipients R.T. Hayden, Z. Gu, W. Liu, R. Lovins, K. Kasow, P. Woodard, K. Srivastava, W. Leung. Risk factors for hemorrhagic cystitis in pediatric allogeneic hematopoietic stem cell transplant recipients. Transpl Infect Dis 2015: 17: 234–241. All rights reserved Abstract: Background. Hemorrhagic cystitis (HC) results in significant morbidity among hematopoietic stem cell transplant (HSCT) recipients. Several potential causes for HC have been postulated, including viral infection, but definitive evidence is lacking, particularly in pediatric HSCT patients. Methods. Ninety pediatric HSCT recipients were prospectively tested on a weekly basis for adenovirus (ADV) and BK virus (BKV) by quantitative real-time polymerase chain reaction in blood and urine samples. Results were correlated with the occurrence of grade II–IV HC. The odds ratio (OR) of HC (95% confidence interval) for BKV ≥1 9 109 copies/mL of urine was 7.39 (1.52, 35.99), with a Pvalue of 0.013. Those with acute graft-versus-host disease (aGVHD) also had higher odds of developing HC, with an OR of 5.34. Given a 20% prevalence rate of HC, positive and negative predictive values of 29% and 95% were seen with a cutoff of 109 copies/mL. Results. BK viremia did not reach significance as a risk factor for development of HC (P = 0.06). Only 8 patients showed ADV viruria and 7 showed ADV viremia; all had low viral loads and 4 had no evidence of HC. Conclusion. HC in pediatric HSCT is correlated most strongly to elevated urinary viral load of BKV and to aGVHD, but less strongly to BK viremia.
R.T. Hayden1, Z. Gu1, W. Liu2, R. Lovins3, K. Kasow4, P. Woodard5, K. Srivastava2, W. Leung3 1
Pathology Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA, 2Biostatistics Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA, 3Department of Bone Marrow Transplantation & Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA, 4Bone Marrow and Stem Cell Transplant Program, University of North Carolina, Chapel Hill, North Carolina, USA, 5 Genentech, Inc., South San Francisco, California, USA Key words: BK virus; bone marrow transplant; hematopoietic stem cell transplant; hemorrhagic cystitis; pediatric transplant Correspondence to: Randall Hayden, MD, Department of Pathology, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Mail Stop #250, Memphis, TN 38105-2794, USA Tel.: 1-901-595-3525 Fax: 1-901-595-3100 E-mail: [email protected]
Received 5 August 2014, revised 4 December 2014, accepted for publication 18 January 2015 DOI: 10.1111/tid.12364 Transpl Infect Dis 2015: 17: 234–241
Hemorrhagic cystitis (HC) represents a significant cause of morbidity in hematopoietic stem cell transplant (HSCT) patients; its incidence varies, with reports of 12% and 16% in 2 recent studies (1, 2) and 21% shown among pediatric patients (2). High-grade HC can necessitate multiple transfusions, extended hospitalization, and result in severe pain and urinary obstruction (3). Earlyonset HC typically occurs pre-engraftment, usually resolves spontaneously, and is usually attributed to conditioning therapy, particularly high-dose cyclophosphamide. In contrast, late onset (post-engraftment) HC typically occurs a month or more after engraftment and
234
may follow a prolonged course (4). The causes of late onset HC are less well defined, and several factors may be involved. Factors that have been associated to a greater or lesser extent by various authors include graftversus-host disease (GVHD), graft source, degree of transplant mismatch, severity of myeloablative conditioning, use of busulfan, and viral infection, particularly with adenovirus (ADV) or BK virus (BKV) (1, 3–6). An association between adenoviruria and HC has been noted, primarily in Japanese populations (7, 8); however, most published literature focuses on BKV as a potential causative factor in the development of late onset HC.
Hayden et al: Hemorrhagic cystitis in pediatric transplant patients
BKV is a human polyomavirus with a high seroprevalence in adults (up to 90% in some studies). Most primary infections occur at a young age (approximately 50% seropositive by 10 years) and are either asymptomatic or associated with fever and upper respiratory tract symptoms (1, 9). Following primary infection, the virus persists in urothelial cells and can be transiently shed asymptomatically in children, the elderly, and in association with pregnancy, diabetes mellitus, and immunosuppressive conditions such as human immunodeficiency virus infection and transplantation. BKV is seen as a primary cause of nephropathy following allogeneic renal transplantation (BKV-associated nephropathy [BKVAN]), resulting in graft dysfunction, ureteral stenosis, and graft loss. While histopathologic findings are required for definitive diagnosis, increased viral load in blood or urine are predictive of BKVAN, and routine monitoring, typically by real-time polymerase chain reaction (PCR) is now standard-of-care in many settings, with elevated blood viral load tending to have a higher predictive value than increased viruria (10, 11). The association between BKV and late-onset HC is less well established than that with BKVAN. However, several studies have shown a variable association between elevated BK viral burden in blood or urine and the development of HC after HSCT (1, 5, 6, 12–15). The majority of these studies have been in the adult transplant population, but a smaller number of investigators have examined the question in pediatric patients. Only one recently published work looked at the association between BK viremia and HC (16); however, that study did not include urinary viral loads and was limited to opportunistic testing of patients based on clinical suspicion (typically, exhibiting at least microscopic hematuria). Our present study is unique in its longitudinal follow-up and prospective sampling of both blood and urine from all eligible asymptomatic pediatric allogeneic HSCT patients at a major pediatric oncology center, with quantitative analysis of all samples for both BKV and ADV by real-time PCR methods.
Materials and methods Study population The study population included all children undergoing allogeneic HSCT at St. Jude Children’s Research Hospital from December 2006 to May 2012. During this period, 236 allogeneic HSCTs were performed in 220 patients. Reasons for exclusion included the following factors: patient too young to reliably provide
serial urine collections (not eligible, 35 patients); transplant during a temporary pause in accrual for interim analysis (21 patients); patient receiving a subsequent HSCT after completion of initial participation in this study (16 transplants); lack of consent to study participation (27 patients); and enrollment on study, but patient not proceeding with the planned HSCT (5 patients). The remainder (42 patients) were not enrolled for a variety of reasons, largely related to administrative and logistical issues. At the conclusion of the study, 90 patients were included for analysis (Table 1). This study was approved by the St. Jude Children’s Research Hospital institutional review board.
Samples Urine samples were obtained once weekly for 15 weeks, for quantitative adenoviral and BK viral PCR and for routine urinalysis. Blood samples were routinely collected weekly for quantitative viral PCR testing as a standard of care (ADV PCR) and per protocol for all allogeneic HSCT for up to approximately 100 days (15 weeks) post transplant; remnant blood from the same sample was used for quantitative adenoviral and BK viral testing for this study. Viral load tests were run as samples were received, in the same prospective timeframe as collection. Laboratory values for protocol-driven tests were not reported to clinicians. These data were collected and stored in a password-protected computer database prior to analysis.
Clinical data collection and definitions Demographic data and information regarding underlying disease and transplant were collected on study entry, as shown in Table 1. Transplant data included whether or not anti-CD3 antibody (OKT3) or antithymocyte globulin were administered and whether the graft was ex vivo T-cell depleted. Pre-transplant lab values were recorded, including CD4+ and CD8+ T-cell counts and serum creatinine. Ongoing chart review recorded occurrence of GVHD, fluoroquinolone administration, steroid use, and treatment with other immunosuppressive medications. HC was graded according to National Cancer Institute criteria (17). Off-study criteria included failure to proceed with planned transplant; patient death; development of anuria; 100 days post HSCT, if not developing HC, or if HC resolved before day 100 post HSCT; or day of resolution of HC event, if beyond 100 days post HSCT. Other off-study
Transplant Infectious Disease 2015: 17: 234–241
235
Hayden et al: Hemorrhagic cystitis in pediatric transplant patients
Patient characteristics Variable
Subgroup
N
Percent
Diagnosis
ALL
36
40.0
AML/MDS
Donor type
Gender
Race
32
35.6
Acute biphenotypic leukemia
2
2.2
Severe aplastic anemia/PNH
11
12.2
CML
1
1.1
Bone marrow failure syndrome
2
2.2
X-linked lymphoproliferative disorder
1
1.1
Lymphoma
4
4.4
Sickle cell disease
1
1.1
Father
13
14.4
Mother
11
12.2
Sibling
17
18.9
Unrelated
49
54.4
Female
43
47.8
Male
47
52.2
Other
21
23.3
69
76.7
Total body irradiation
White
47
52.2
Anti-thymocyte globulin
47
52.2
Levofloxacin or ciprofloxacina
18
20
OKT3
15
16.7
T-cell depleted
24
26.7
Acute GVHD Hemorrhagic cystitis
14
15.6
No
71
78.9
Yes
19
21.1
a
Defined as starting dates before hemorrhagic cystitis (HC) onset date or within 104 days of HSCT without HC. ALL, acute lymphoblastic leukemia; AML/MDS, acute myeloid leukemia/myelodysplastic syndrome; PNH, paroxysmal nocturnal hemoglobinuria; CML, chronic myeloid leukemia; OKT3, anti-CD3 antibody; GVHD, graft-versus-host disease; HSCT, hematopoietic stem cell transplant.
Table 1
criteria included graft failure and re-transplant, disease progression, or relapse requiring additional chemotherapy, voluntary withdrawal, and loss of contact with patient.
extraction and amplification control. Purified nucleic acid solution was stored at 70°C until testing. The samples were tested using quantitative real-time PCR assays for detection of ADV and BKV as previously described (18, 19).
Detection of ADV and BKV Statistical analysis A total of 647 pairs of whole blood and urine specimens were collected. DNA was extracted from 200 lL of sample using the EZ1 Virus Mini Kit on a BioRobot EZ1 workstation (QIAGEN, Valencia, California, USA). Internal amplification control (Luminex Corp., Austin, Texas, USA) was added prior to extraction, to act as an
236
A total of 90 patients who underwent transplantation were included in the analysis. The association between the factors of interest (listed in Table 2 and categorized as binary variables) and development of HC was evaluated using Fisher’s exact test in a univariate
Transplant Infectious Disease 2015: 17: 234–241
Hayden et al: Hemorrhagic cystitis in pediatric transplant patients
Frequency of patient characteristics and hemorrhagic cystitis (HC)
Variable Gender
HC
No HC
Fisher’s exact
Subgroup
N (%)
N (%)
P-value
Female
10 (23.3)
33 (76.6)
9 (19.1)
38 (80.9)
Male Race
Total body irradiation
Other
5 (23.8)
16 (76.2)
White
14 (20.3)
55 (79.7)
No
11 (25.6)
32 (74.4)
8 (17.0)
39 (83.0)
Yes ATG
OKT3
T-cell depleted
aGVHD (Grade 3, 4)
7 (16.3)
36 (83.7)
Yes
No
12 (25.5)
35 (74.5)
No
15 (20.0)
60 (80.0)
Yes
4 (26.7)
11 (73.3)
No
15 (22/7)
51 (77.3)
Yes
4 (16.7)
20 (83.3)
12 (15.8)
64 (84.2)
No Yes
Levofloxacin or ciprofloxacin
No Yes
7 (50.0)
7 (50.0)
13 (18.1)
59 (81.9)
6 (33.3)
12 (66.7)
0.80
0.76
0.44
0.31
0.51
0.77
0.009
0.20
Bold P-value is significant. ATG, anti-thymocyte globulin; OKT3, anti-CD3 antibody; aGVHD, acute graft-versus-host disease.
Table 2
manner. The relationship between urine BKV levels and HC was evaluated using Cox’s proportional hazards model and logistic regression. In Cox’s proportional hazards model, time to developing HC was modeled as a function of acute GVHD (aGVHD) (Grade 3 and 4 vs. Grade
Risk factors for hemorrhagic cystitis in pediatric allogeneic hematopoietic stem cell transplant recipients R.T. Hayden, Z. Gu, W. Liu, R. Lovins, K. Kasow, P. Woodard, K. Srivastava, W. Leung. Risk factors for hemorrhagic cystitis in pediatric allogeneic hematopoietic stem cell transplant recipients. Transpl Infect Dis 2015: 17: 234–241. All rights reserved Abstract: Background. Hemorrhagic cystitis (HC) results in significant morbidity among hematopoietic stem cell transplant (HSCT) recipients. Several potential causes for HC have been postulated, including viral infection, but definitive evidence is lacking, particularly in pediatric HSCT patients. Methods. Ninety pediatric HSCT recipients were prospectively tested on a weekly basis for adenovirus (ADV) and BK virus (BKV) by quantitative real-time polymerase chain reaction in blood and urine samples. Results were correlated with the occurrence of grade II–IV HC. The odds ratio (OR) of HC (95% confidence interval) for BKV ≥1 9 109 copies/mL of urine was 7.39 (1.52, 35.99), with a Pvalue of 0.013. Those with acute graft-versus-host disease (aGVHD) also had higher odds of developing HC, with an OR of 5.34. Given a 20% prevalence rate of HC, positive and negative predictive values of 29% and 95% were seen with a cutoff of 109 copies/mL. Results. BK viremia did not reach significance as a risk factor for development of HC (P = 0.06). Only 8 patients showed ADV viruria and 7 showed ADV viremia; all had low viral loads and 4 had no evidence of HC. Conclusion. HC in pediatric HSCT is correlated most strongly to elevated urinary viral load of BKV and to aGVHD, but less strongly to BK viremia.
R.T. Hayden1, Z. Gu1, W. Liu2, R. Lovins3, K. Kasow4, P. Woodard5, K. Srivastava2, W. Leung3 1
Pathology Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA, 2Biostatistics Department, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA, 3Department of Bone Marrow Transplantation & Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA, 4Bone Marrow and Stem Cell Transplant Program, University of North Carolina, Chapel Hill, North Carolina, USA, 5 Genentech, Inc., South San Francisco, California, USA Key words: BK virus; bone marrow transplant; hematopoietic stem cell transplant; hemorrhagic cystitis; pediatric transplant Correspondence to: Randall Hayden, MD, Department of Pathology, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Mail Stop #250, Memphis, TN 38105-2794, USA Tel.: 1-901-595-3525 Fax: 1-901-595-3100 E-mail: [email protected]
Received 5 August 2014, revised 4 December 2014, accepted for publication 18 January 2015 DOI: 10.1111/tid.12364 Transpl Infect Dis 2015: 17: 234–241
Hemorrhagic cystitis (HC) represents a significant cause of morbidity in hematopoietic stem cell transplant (HSCT) patients; its incidence varies, with reports of 12% and 16% in 2 recent studies (1, 2) and 21% shown among pediatric patients (2). High-grade HC can necessitate multiple transfusions, extended hospitalization, and result in severe pain and urinary obstruction (3). Earlyonset HC typically occurs pre-engraftment, usually resolves spontaneously, and is usually attributed to conditioning therapy, particularly high-dose cyclophosphamide. In contrast, late onset (post-engraftment) HC typically occurs a month or more after engraftment and
234
may follow a prolonged course (4). The causes of late onset HC are less well defined, and several factors may be involved. Factors that have been associated to a greater or lesser extent by various authors include graftversus-host disease (GVHD), graft source, degree of transplant mismatch, severity of myeloablative conditioning, use of busulfan, and viral infection, particularly with adenovirus (ADV) or BK virus (BKV) (1, 3–6). An association between adenoviruria and HC has been noted, primarily in Japanese populations (7, 8); however, most published literature focuses on BKV as a potential causative factor in the development of late onset HC.
Hayden et al: Hemorrhagic cystitis in pediatric transplant patients
BKV is a human polyomavirus with a high seroprevalence in adults (up to 90% in some studies). Most primary infections occur at a young age (approximately 50% seropositive by 10 years) and are either asymptomatic or associated with fever and upper respiratory tract symptoms (1, 9). Following primary infection, the virus persists in urothelial cells and can be transiently shed asymptomatically in children, the elderly, and in association with pregnancy, diabetes mellitus, and immunosuppressive conditions such as human immunodeficiency virus infection and transplantation. BKV is seen as a primary cause of nephropathy following allogeneic renal transplantation (BKV-associated nephropathy [BKVAN]), resulting in graft dysfunction, ureteral stenosis, and graft loss. While histopathologic findings are required for definitive diagnosis, increased viral load in blood or urine are predictive of BKVAN, and routine monitoring, typically by real-time polymerase chain reaction (PCR) is now standard-of-care in many settings, with elevated blood viral load tending to have a higher predictive value than increased viruria (10, 11). The association between BKV and late-onset HC is less well established than that with BKVAN. However, several studies have shown a variable association between elevated BK viral burden in blood or urine and the development of HC after HSCT (1, 5, 6, 12–15). The majority of these studies have been in the adult transplant population, but a smaller number of investigators have examined the question in pediatric patients. Only one recently published work looked at the association between BK viremia and HC (16); however, that study did not include urinary viral loads and was limited to opportunistic testing of patients based on clinical suspicion (typically, exhibiting at least microscopic hematuria). Our present study is unique in its longitudinal follow-up and prospective sampling of both blood and urine from all eligible asymptomatic pediatric allogeneic HSCT patients at a major pediatric oncology center, with quantitative analysis of all samples for both BKV and ADV by real-time PCR methods.
Materials and methods Study population The study population included all children undergoing allogeneic HSCT at St. Jude Children’s Research Hospital from December 2006 to May 2012. During this period, 236 allogeneic HSCTs were performed in 220 patients. Reasons for exclusion included the following factors: patient too young to reliably provide
serial urine collections (not eligible, 35 patients); transplant during a temporary pause in accrual for interim analysis (21 patients); patient receiving a subsequent HSCT after completion of initial participation in this study (16 transplants); lack of consent to study participation (27 patients); and enrollment on study, but patient not proceeding with the planned HSCT (5 patients). The remainder (42 patients) were not enrolled for a variety of reasons, largely related to administrative and logistical issues. At the conclusion of the study, 90 patients were included for analysis (Table 1). This study was approved by the St. Jude Children’s Research Hospital institutional review board.
Samples Urine samples were obtained once weekly for 15 weeks, for quantitative adenoviral and BK viral PCR and for routine urinalysis. Blood samples were routinely collected weekly for quantitative viral PCR testing as a standard of care (ADV PCR) and per protocol for all allogeneic HSCT for up to approximately 100 days (15 weeks) post transplant; remnant blood from the same sample was used for quantitative adenoviral and BK viral testing for this study. Viral load tests were run as samples were received, in the same prospective timeframe as collection. Laboratory values for protocol-driven tests were not reported to clinicians. These data were collected and stored in a password-protected computer database prior to analysis.
Clinical data collection and definitions Demographic data and information regarding underlying disease and transplant were collected on study entry, as shown in Table 1. Transplant data included whether or not anti-CD3 antibody (OKT3) or antithymocyte globulin were administered and whether the graft was ex vivo T-cell depleted. Pre-transplant lab values were recorded, including CD4+ and CD8+ T-cell counts and serum creatinine. Ongoing chart review recorded occurrence of GVHD, fluoroquinolone administration, steroid use, and treatment with other immunosuppressive medications. HC was graded according to National Cancer Institute criteria (17). Off-study criteria included failure to proceed with planned transplant; patient death; development of anuria; 100 days post HSCT, if not developing HC, or if HC resolved before day 100 post HSCT; or day of resolution of HC event, if beyond 100 days post HSCT. Other off-study
Transplant Infectious Disease 2015: 17: 234–241
235
Hayden et al: Hemorrhagic cystitis in pediatric transplant patients
Patient characteristics Variable
Subgroup
N
Percent
Diagnosis
ALL
36
40.0
AML/MDS
Donor type
Gender
Race
32
35.6
Acute biphenotypic leukemia
2
2.2
Severe aplastic anemia/PNH
11
12.2
CML
1
1.1
Bone marrow failure syndrome
2
2.2
X-linked lymphoproliferative disorder
1
1.1
Lymphoma
4
4.4
Sickle cell disease
1
1.1
Father
13
14.4
Mother
11
12.2
Sibling
17
18.9
Unrelated
49
54.4
Female
43
47.8
Male
47
52.2
Other
21
23.3
69
76.7
Total body irradiation
White
47
52.2
Anti-thymocyte globulin
47
52.2
Levofloxacin or ciprofloxacina
18
20
OKT3
15
16.7
T-cell depleted
24
26.7
Acute GVHD Hemorrhagic cystitis
14
15.6
No
71
78.9
Yes
19
21.1
a
Defined as starting dates before hemorrhagic cystitis (HC) onset date or within 104 days of HSCT without HC. ALL, acute lymphoblastic leukemia; AML/MDS, acute myeloid leukemia/myelodysplastic syndrome; PNH, paroxysmal nocturnal hemoglobinuria; CML, chronic myeloid leukemia; OKT3, anti-CD3 antibody; GVHD, graft-versus-host disease; HSCT, hematopoietic stem cell transplant.
Table 1
criteria included graft failure and re-transplant, disease progression, or relapse requiring additional chemotherapy, voluntary withdrawal, and loss of contact with patient.
extraction and amplification control. Purified nucleic acid solution was stored at 70°C until testing. The samples were tested using quantitative real-time PCR assays for detection of ADV and BKV as previously described (18, 19).
Detection of ADV and BKV Statistical analysis A total of 647 pairs of whole blood and urine specimens were collected. DNA was extracted from 200 lL of sample using the EZ1 Virus Mini Kit on a BioRobot EZ1 workstation (QIAGEN, Valencia, California, USA). Internal amplification control (Luminex Corp., Austin, Texas, USA) was added prior to extraction, to act as an
236
A total of 90 patients who underwent transplantation were included in the analysis. The association between the factors of interest (listed in Table 2 and categorized as binary variables) and development of HC was evaluated using Fisher’s exact test in a univariate
Transplant Infectious Disease 2015: 17: 234–241
Hayden et al: Hemorrhagic cystitis in pediatric transplant patients
Frequency of patient characteristics and hemorrhagic cystitis (HC)
Variable Gender
HC
No HC
Fisher’s exact
Subgroup
N (%)
N (%)
P-value
Female
10 (23.3)
33 (76.6)
9 (19.1)
38 (80.9)
Male Race
Total body irradiation
Other
5 (23.8)
16 (76.2)
White
14 (20.3)
55 (79.7)
No
11 (25.6)
32 (74.4)
8 (17.0)
39 (83.0)
Yes ATG
OKT3
T-cell depleted
aGVHD (Grade 3, 4)
7 (16.3)
36 (83.7)
Yes
No
12 (25.5)
35 (74.5)
No
15 (20.0)
60 (80.0)
Yes
4 (26.7)
11 (73.3)
No
15 (22/7)
51 (77.3)
Yes
4 (16.7)
20 (83.3)
12 (15.8)
64 (84.2)
No Yes
Levofloxacin or ciprofloxacin
No Yes
7 (50.0)
7 (50.0)
13 (18.1)
59 (81.9)
6 (33.3)
12 (66.7)
0.80
0.76
0.44
0.31
0.51
0.77
0.009
0.20
Bold P-value is significant. ATG, anti-thymocyte globulin; OKT3, anti-CD3 antibody; aGVHD, acute graft-versus-host disease.
Table 2
manner. The relationship between urine BKV levels and HC was evaluated using Cox’s proportional hazards model and logistic regression. In Cox’s proportional hazards model, time to developing HC was modeled as a function of acute GVHD (aGVHD) (Grade 3 and 4 vs. Grade
