b. Newly appointed chair: Paul Szabolcs, MD, Duke University Medical Center Telephone: ;

Transcription

1 A G E N D A CIBMTR WORKING COMMITTEE FOR INFECTION AND IMMUNE RECONSTITUTION Tampa, Florida Friday, February 13, 2009, 12:15 pm - 2:15 pm Co-Chair: Co-Chair: Co-Chair: Statisticians: Scientific Director: Jan Storek, MD, PhD, University of Calgary, Calgary, Alberta, Canada Telephone: ; Fax: ; jstorek@ucalgary.ca Jo-Anne Young, MD University of Minnesota, Minneapolis, Minnesota Telephone: ; Fax: ; vanbu004@umn.edu Juan Gea-Banacloche, MD, National Institutes of Health, Bethesda, Maryland. Telephone: ; banacloj@mail.nih.gov Manisha Kukreja, MBBS, MPH, CIBMTR Statistical Center Telephone: ; Fax: ; mkukreja@mcw.edu Kwang Woo Ahn, PhD, CIBMTR Statistical Center Telephone: ; kwooahn@mcw.edu John P Klein, PhD, CIBMTR Statistical Center; klein@mcw.edu Marcie Tomblyn, MD, MS University of Minnesota, Minneapolis, Minnesota Telephone: ; Fax: ; tombl001@umn.edu 1. Introduction a. Minutes of February, 2008 minutes (Attachment 1) b. Newly appointed chair: Paul Szabolcs, MD, Duke University Medical Center Telephone: ; szabo001@mc.duke.edu 2. Published or submitted papers a. LE04-02 Gupta V, Tomblyn M, Pedersen TL, Atkins HL, Battiwalla M, Gress RE, Pollack MS, Storek J, Thompson JC, Tiberghien P, Young J, Ribaud P, Horowitz MM, Keating A. Allogeneic and syngeneic hematopoietic cell transplantation in HIV-positive patients: A report from the Center for International Blood and Marrow Transplant Research (CIBMTR). Revised and submitted to BBMT. b. GV02-02 Marcie Tomblyn, Manisha Kukreja, Sergey Tarima, Mahmoud D. Aljurf, Fahad Al Mohareb, Brian J. Bolwell, Jean-Yves Cahn, Matthew H. Carabasi, Robert Peter Gale, Ronald E. Gress, Vikas Gupta, Gregory A. Hale, Per Ljungman, Richard T. Maziarz, Jan Storek, John R.Wingard, Jo-Anne Young, Mary M. Horowitz, Karen K Ballen. No Effect of Recipient or Donor Hepatitis B and/or Hepatitis C serostatus on the Outcomes of Related Donor Allogeneic Hematopoietic Cell Transplantation; Under revision and plan for submission to BBMT

2 4. Studies in progress a. LE04-01 CMV infection and mortality after HSCT Data file preparation (M Boeckh) (Attachment 2) b. R04-90 NK interaction and infection (M Tomblyn/J Young) Manuscript Preparation c. IN05-02 Zygomycoses in HSCT (M Tomblyn/S Trifilio) Data file preparation (Attachment 4) d. IN06-01 Breakthrough PCP (P.jiroveci) as Protocol Development a function of prophylaxis regimen (K Williams) (Attachment 5) e. IN07-01 Blood stream infection by VRE after Protocol Development Allogeneic HSCT (M Robien/G Papanicolaou) (Attachment 6) f. IN07-02 Epidemiology of infections in children and Protocol Development young adults after HSCT (R Hayden) (Attachment 7) g. IN07-03 Incidence of Herpes Zoster within 100 Protocol Development days post HSCT (M Salvaggio) (Attachment 8) h. IN08-01 NMAR vs MAR transplantation for early bacterial, Protocol Development fungal and viral infections in patients with AML in CR1 (C Ustun) (Attachment 9) 5. Future/ Proposed studies a. PROP # Donor and Recipient CMV Serostatus and Outcome of Pediatric Allogeneic HSCT for Acute Leukemia in the Era of CMV Preemptive Therapy and Prophylaxis (C Behrendt) (Attachment 10) b. PROP # Outcomes of allogeneic hematopoietic stem cell transplantation for patients with and without pre-existing fungal infections (R Maziarz) (Attachment 11) 6. Other business a. Guidelines for Preventing Infections among Hematopoietic Stem Cell Transplant Recipients: A Global Perspective (an update of the 2000 Recommendations of CDC, IDSA, and ASBMT) b. Infection eras 2009: Infection Data Collected 1995 current on CIBMTR Research Forms: Infection and Immune Reconstitution Working Committee (J Young/ M Tomblyn) (Attachment 12) c. Introduction to newly appointed chair of IIRWC, Paul Szabolcs, MD; farewell to outgoing chair, Jan Storek, MD.

3 Not for publication or presentation Attachment 1 MINUTES CIBMTR WORKING COMMITTEE FOR INFECTION AND IMMUNE RECONSTITUTION San Diego, California Friday, February 15, 2008, 2:45 pm - 4:45 pm Co-Chair: Co-Chair: Co-Chair: Statisticians: Scientific Director: Ronald Gress, MD, National Institutes of Health, Bethesda, MD Telephone: ; Fax: ; gressr@exchange.nih.gov Jan Storek, MD, PhD, University of Calgary, Calgary, Alberta, Canada Telephone: ; Fax: ; jstorek@ucalgary.ca Jo-Anne Young, MD, University of Minnesota, Minneapolis, MN Telephone: ; Fax: ; vanbu004@umn.edu Manisha Kukreja, MBBS, MPH, CIBMTR Statistical Center Telephone: ; Fax: ; mkukreja@mcw.edu Sergey Tarima, PhD, CIBMTR Statistical Center Telephone: ; Fax: ; starima@mcw.edu Marcie Tomblyn, MD, MS, University of Minnesota, Minneapolis, MN Telephone: ; Fax: ; tombl001@umn.edu 1. Introduction The CIBMTR Working Committee for Infection and Immune Reconstitution was held on Friday, February 15, 2008, at 2:45 pm. Dr Ron Gress introduced Manisha Kukreja as the statistician and Dr Marcie Tomblyn as Scientific Director of the working committee. Dr Juan Gea-Bannacloche, from National Institutes of Health was introduced as newly appointed chair of the working committee who will replace outgoing chair Dr Gress. With Dr. Gress, Dr Jo-Anne Young and Dr Jan Storek co-chaired the meeting. The minutes from the 2007 Tandem meeting held in Keystone, Colorado, were approved by committee members. Attendees were asked to sign the attendance sheet in order to maintain committee membership and to use paper ballot voting sheets for studies in progress and new proposals. Members were asked to vote a level of priority for each study that would be presented. An overhead regarding how to submit new proposals to the cibmtr.org website was also explained by Dr Gress. 2. Accrual summary Dr Jan Storek briefly summarized the accrual summary. There are 20,717 autologous transplant and 49,875 allogeneic transplants reported to the CIBMTR between 1995 through A total of 6% of autologous transplant cases died of infections and 18% of allogeneic transplant cases died of infections. Dr Jan Storek also mentioned there is a difference between the registered transplants and those transplants for which the comprehensive report forms are available. The infection related information is available on comprehensive report forms. It was brought to the committee s attention that they can access the website to see what data are being collected. Dr Tomblyn mentioned that new harmonized forms are available for Forms Net 2.0 which became active on December 3 rd 2007.

4 Not for publication or presentation Attachment 1 3. Published or submitted papers moderated by Dr Jo-Anne Young a. LE04-02 Gupta V, Tomblyn M, Pedersen TL, Atkins HL, Battiwalla M, Gress RE, Pollack MS, Storek J, Thompson JC, Tiberghien P, Young J, Ribaud P, Horowitz MM, Keating A. Allogeneic and syngeneic hematopoietic cell transplantation in HIV-positive patients: A report from the Center for International Blood and Marrow Transplant Research (CIBMTR). Submitted. 4. Studies in progress moderated by Dr Jo-Anne Young a. GV02-02 Transplant outcomes from Hepatitis B and Hepatitis C positive donors (K Ballen/ M Tomblyn) Dr Ballen presented the updates for this study. The objectives of the study included analyzing the effect of viral hepatitis (either B or C) infection in recipients compared to in donors and compared to both recipients and donors with infection. The second objective was to identify any differences in the outcomes of Hepatitis B versus Hepatitis C infection. The study had 161 cases and 256 matched controls. Multivariate models were built among the four groups (R (B/C)+, D(B/C)+, R+D(B/C)+, and controls) and 3 groups (HepB, HepC, and controls) to detect the difference in the outcomes at 5% significance level. The results of the study indicated that the risk of TRM, OS, agvhd, and cgvhd are not significantly different among the cases and controls, so that patients should not be denied transplants taking into consideration donor availability. Amy Langston asked if there were liver biopsy prior to transplant and Dr Tomblyn replied in less than 20% cases. Amy had question about LFT s and Dr Tomblyn replied that AST was examined, but did not prove important in the multivariate analysis. There was also a question about the viral loads and Dr. Tomblyn updated the committee members that data on viral loads was available on less than 20% of cases. The goal is to start preparing manuscript for this study. b. LE04-01 CMV infection and mortality after HSCT (Boeckh) Dr Boeckh highlighted that the goal of the study is to look at CMV infection prevention strategies and outlined the patient, disease, and transplant characteristics in the table. He mentioned that the internet based survey on CMV prevention strategies and antiviral prophylaxis was sent out to the centers and the data is expected to be compiled and sent to the CIBMTR for analysis by June 08. The CMV survey was accepted as an abstract (An International Comparison of Current Strategies to Prevent Herpes virus and Fungal Diseases in HCT Recipients) at 2008 BMT Tandem meeting and was presented by Judson Heugel. He also mentioned that this survey will address whether CMV serostatus has an impact on outcomes and also provide data on the antiviral strategies. The issue raised was that it is not clear how serostatus should be prioritized, as US data vary from European data. The discussion ended with this thought. c. R04-90 NK interaction and infection (J Young) Dr Jeff Miller presented the update for this study. The goal of this study is to compare the GVHD and infection outcomes for patients with KIR ligand matching and mismatching between donor and recipient. The patient population from which to draw was a set of > 200 transplant recipients with detailed, audited infectious disease data from a prior project. The study population had few patients with DNA available for testing, resulting in 70 KIR donor/recipient matches and 17 KIR mismatches, and therefore will not be able to determine anything definitive. Another approach for analysis was presented by Dr. Jeff Miller regarding the available DNA for this study. It was discussed that NK receptors can be activating as well as inhibiting. In mice, analogous receptors recognize homologous proteins. Presence of activating receptors had a relapse protective effect and TRM protective effect. It was

5 Not for publication or presentation Attachment 1 suggested that the cases be re-categorized as activating KIR or not, and then analyzed (instead of analyzing based on the KIR match status). d. IN05-02 Zygomycoses in HSCT (M Tomblyn/S Trifilio) Dr Marcie Tomblyn presented the update for this study. The goals of the study are to determine the incidence of atypical mold infections in HSCT patients and to examine the effects of newer antifungal agents on the incidence of atypical mold infections. At the last Tandem meeting, due to complexity with obtaining the detailed antifungal prophylaxis and treatment, the committee recommended revision of the protocol to a descriptive analysis of non-aspergillus mold infections. But the statistical meeting group at the registry suggested to include the comparison control group, and advised revising the protocol. Dr Tomblyn mentioned that there 102 cases with atypical mold infection from 1995 to 2005, of all the ages and all diseases. The majority of infections with atypical mold are within first 3 months, but 29 patients had infection documented after 3 months. It was suggested to truncate the study at 3 months of follow up. The tables will be revised adding the comparison group, and also the HLA match classification will be updated in the table. This study will be considered for potential Tandem abstract for year e IN06-01 Breakthrough PCP (P.jiroveci) as a function of prophylaxis regimen (K Williams) Dr Kirsten Williams presented the updates for this study. The goals of the study are to determine the PCP incidence in BMT population and to determine the relationship between risk of PCP and the use of various prophylactic agents. This study requires supplemental data collection to obtain information about type, dosage, and timing of PCP prophylaxis. Dr William presented the list of questions to be asked on supplemental form. She also mentioned that this study included 180 allogeneic and 52 autologous transplant cases when counting only first transplant. There are many pediatric patients and numbers of cases decline in later years of transplant. Karen questioned if day of onset is defined but Dr. Tomblyn answered that we do not know yet if we are only limiting the patient population to first transplant only. There was also a question about adding CD34 count data, but Dr Tomblyn explained the difficulty obtaining this information. Dr. Mark Robien asked if it is possible to analyze the impact of cellcept and echinocardins on the incidence of PCP. The discussion ended with Dr Jan Storek suggesting reviewing the objectives of the study. The goal is to develop the final supplemental form and start collecting data on supplemental forms. f. IN07-01 Bloodstream infection (BSI) by VRE after allogeneic HSCT (D Weinstock) Dr Tomblyn outlined the patient characteristics of those patients reported to the CIBMTR between 2002 and 2006 who received allogeneic transplant and developed enterococcal bloodstream infections (VRE/VSE) prior to day 30 post transplant vs. non enterococcal bloodstream infection by day 30 vs. no BSI group. Dr Tomblyn mentioned that study initially requested to include patients starting in However, data for enterococcal infections were not collected before There are 129 potential cases of enterococcal infection by day 30 and these need confirmation of resistance vs. sensitivity status. Dr Tomblyn announced the need to recruit a new study chair for this study since Dr. Weinstock has requested to withdraw. Dr Mark Robien and Dr Genovefa (Zenia) Papanicolaou offered to co-chair this study. Mark Robien raised the issue about the high grade vs. low grade bacteremia, and Jean asked about the issues of capturing cause of death contribution by enterococcus.

6 Not for publication or presentation Attachment 1 g. IN07-02 Epidemiology of infections in children and young adults after HSCT (R Hayden) Dr Tomblyn summarized the post transplant infections for the patients who underwent autologous or allogeneic transplant and were reported to the CIBMTR from 1985 to This study could not move further because of lack of statistical hours last year. Dr Jan Storek mentioned that he would like to increase the age limit of the study subjects, and would like to see the ratios of later infections, including those later infections after the transplant when data are underreported. Amy Langston suggested that the ratio data may still be limited since the transplant centers are more likely to be contacted about the serious infections with less, if any, data obtained for less serious infections. h. IN07-03 Incidence of Herpes Zoster within 100 days post HSCT (M Salvaggio) Dr Jennifer Holter presented the review of this study. This study aims to determine the incidence of herpes zoster infections among hematopoietic stem cell recipients and to assess the risk factors associated with the development of Herpes zoster infections in HSCT recipients. She mentioned that 571 cases reported HZV infections post transplant from The incidence rate represents what has been previously mentioned in the literature. The committee expressed concern regarding varied or not good guidelines on prophylaxis or duration of antiviral therapy at individual centers and that this information will need to be obtained. Dr. Mark Robien asked if FHCRC data already address this and Dr Boeckh noted that his study (LE04-01) did obtain this information and could be used in this study. The committee decided to truncate and focus this study on only the period of day (early zoster), as Amy Langston added that we might not hear about the late infections. Dr John Zaia reported that prior zoster vaccine studies have found a rate of simplex infections accounting for up to 20% of zoster cases when virologically confirmed, so reliance on clinical pattern recognition of infection may over report numbers of true cases. He also noted that a better correlate of virologically-confirmed zoster infections in the vaccine studies were those cases that report post-herpetic neuralgia. The incidence of post-herpetic neuralgia is beyond the scope of the current study, but Dr Young pointed out that this is an idea for a future proposal. 5. Future/ Proposed studies a. PROP Comparison of NMAR vs. MAR transplantation for early bacterial, fungal and viral infections in patients with AML in first complete remission. (C Ustun) Dr Ustun presented the comparison of the characteristics of patients with AML in CR1 and underwent myeloablative and non myeloablative allogeneic transplants for early bacterial, viral and fungal infections from 2000 to There are overall 1230 and 454 patients in MAR and NMAR group respectively. The twin transplant, T-cell depleted cases, and HIV positive cases were excluded from study selection criteria. Amy proposed to exclude cord blood as well, as the study has enough number of cases. Dr Gupta asked the reason to limit the population to only CR1 AML patients, and Dr Ustun replied that for interpretation purpose, it is better to have the study population more homogenous and clean. Dr Tomblyn also mentioned some of the limitations about few variables not asked on the CIBMTR forms like duration of WBC, response to antibiotic or antifungal therapy, and information about the cytogenetics. The study will be prioritized based on voting from working committee members. 6. Other business a. Guidelines for Preventing Infections among Hematopoietic Stem Cell Transplant Recipients: A Global Perspective (an update of the 2000 Recommendations of CDC, IDSA, and ASBMT). This was proposed to the CIBMTR from HRSA. An executive committee has

7 Not for publication or presentation Attachment 1 been formed and they identified 8 chairs and co-chairs for each subsection of the document. Each section has a North American and a non-north American chair and co-chair. The group has received monetary support from several organizations including NMDP, ASBMT, EBMT, CDC, IDSA, SHEA, CBMTG, AMMI, and HRSA. All organizational support and contracting is being facilitated through CIBMTR. A medical writer has been contracted to ensure uniformity throughout the document. The timeline includes an in-person meeting in May 2008 with plans for the final document to be submitted for review to the sponsor organizations in July 2008 with final submission no later than September The document will be published simultaneously in BBMT and BMT. The meeting adjourned at 4.45 pm. The allocation of hours for the committee were described in the table below Study number Study title PI Study status 7/1/08 Anticipated study status 6/30/09 GV02- Hep B and C positive donors Ballen/ Tomblyn Manuscript Published 02 LE04-01 CMV infection and mortality Boeckh Data file prep Analysis LE04-02 BMT in HIV + patients Gupta Submit Published R04-90 NK interaction and infection Young Analysis Submit IN05-02 Zygomycosis in HSCT Tomblyn/Trifilio Protocol dev Submit IN06-01 Breakthrough of PCP as function of Williams Data collection Analysis prophylaxis regimen IN07-01 VRE in Allo HSCT Robein/ Protocol dev Analysis Papanicolaou IN07-02 Epidemiology/infections in children after Hayden Protocol dev Data file prep HSCT IN07-03 Herpes zoster post HSCT Salvaggio Protocol dev Data file prep IN08-01 MAR vs NMAR tx for infection in CR1 AML Ustun Protocol dev Data file prep

8 Not for publication or presentation Attachment 2 CIBMTR LE04-01 CMV INFECTION AND MORTALITY AFTER HEMATOPOIETIC STEM CELL TRANSPLANTS FINAL PROTOCOL Study Chair: Study Statistician: Working Committee Chairs: Michael Boeckh, MD Fred Hutchinson Cancer Research Center 1100 Fairview Ave N, D3-100 Seattle, WA Telephone: Fax: mboeckh@fhcrc.org Manisha Kukreja, MBBS, MPH Center for International Blood and Marrow Transplant Research 9200 West Wisconsin Avenue Suite C5500, Milwaukee, WI Telephone: Fax: mkukreja@mcw.edu Ronald E. Gress, MD National Institutes of Health 9000 Rockville Pike Bethesda, MD Telephone: Fax: gressr@exchange.nih.gov

9 Not for publication or presentation Attachment 2 Working Committee Chairs: Jan Storek, MD, PhD University of Calgary 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1 Telephone: Fax: jstorek@ucalgary.ca Jo-Anne van Burik, MD, FACP University of Minnesota 420 Delaware St. SE Minneapolis, MN Telephone: Fax: vanbu004@umn.edu Scientific Director: Marcie Tomblyn, MD, MS University of Minnesota 420 Delaware Street SE Minneapolis, Minnesota Telephone: Fax: tombl001@umn.edu

10 Not for publication or presentation Attachment OBJECTIVES: 1.1 To determine the specific predictors of and reasons for poor survival among CMV seropositive recipients of HSCT We hypothesize that recipient CMV seropositivity is associated with increased treatmentrelated mortality among high-risk patients (such as recipients of mismatched or unrelated transplants or those receiving T-cell depleted transplants), but is not associated with significant risks in low risk (matched sibling) transplants in the era of preemptive therapy. Furthermore, we hypothesize that the suppression of CMV replication via ganciclovir prophylaxis (as opposed to preemptive therapy) attenuates the association between serostatus and mortality among high-risk HSCT recipients, and that high-dose acyclovir prophylaxis in the current era does not alter the association between CMV seropositivity and overall survival. We propose an examination of these issues in a large cohort of patients culled from the Center for Blood and Marrow Transplant Research (CIBMTR). 1.2 To determine whether donor CMV serostatus is associated with outcome in the CMV seropositive or CMV seronegative HSCT recipient. We hypothesize that matching of donor and recipient CMV serostatus (i.e., obtaining a CMV seropositive donor for a seropositive patient, negative donor for negative patient) is associated with optimal outcomes, particularly for recipients of high risk HSCT. We believe that studies to date have had inconsistent results due to inadequate control for other donor characteristics (such as donor age) and/or transplant type (alternate donor and/or T-cell depleted transplants). We will focus on these issues specifically in the course of this study. 2.0 SCIENTIFIC JUSTIFICATION: In the pre-ganciclovir era, cytomegalovirus (CMV) seropositive HSCT recipients were at increased risk for treatment related mortality as a direct result of CMV pneumonia (1). The application of antiviral agents such as ganciclovir in prophylactic or preemptive strategies has dramatically decreased the occurrence of early fatal CMV disease in the HSCT recipient. Despite these accomplishments, it appears that overall survival remains inextricably linked to the patient s pre-transplant CMV serostatus, particularly for high-risk (alternative donor or T-cell depleted) transplants (Table). Thus, the overriding goal of antiviral supportive care-to reduce the treatment-related mortality for the CMV seropositive patient to that of a seronegative patient-has remained elusive. The table below shows selected studies that have examined the influence of recipient CMV serostatus on outcomes after HSCT. The percent of patients who received TCD and alternate donor (other than matched sibling) transplants are noted. TCD, T-cell depleted; OS, overall survival; DFS, disease-free survival; TRM, treatment-related mortality

11 Not for publication or presentation Attachment 2 Ref Patients (N) Disease % TCD % alt donor Results among CMV+ (vs. CMV-) (2) 115 Mixed 95% 0% 24% absolute in OS (P=0.01) (3) 1423 CML 23% 100% 20% relative in DFS (P=0.002) (4) 127 ALL 26% 100% 38% relative in DFS (P=0.05) (5) 106 CML 100% 4% 22% absolute in OS (P=0.006) (6) 125 Mixed 100% 100% 41% absolute in OS (P<0.001) (7) 510 MDS 24% 100% 46% relative in DFS (P=0.001) (8) 1750 Mixed 0% 57% 26% relative in OS (P=0.03) (9) 6978 Mixed 25% 100% 7% absolute in OS (P<0.001) (10) 48 Mixed 100% 100% 41% absolute in TRM (P<0.001) (11) 182 ALL 0% 52% 99% relative in TRM (P=0.01) Given that the direct effects of CMV infection (such as CMV pneumonia) appear to be well controlled, the mechanism by which mortality has been increased among CMV seropositive recipients is not entirely clear. Herein, we propose to investigate this issue in a large cohort of patients that will ideally provide the power necessary to draw firmer conclusions. Perhaps more importantly, the identification of specific patient and/or transplant characteristics that amplify the risk associated with CMV seropositivity would be highly useful in order to develop more targeted antiviral strategies and/or select more appropriate transplant modalities for seropositive patients. The effect of donor CMV serostatus on transplant outcome is more controversial, but may influence transplant outcomes as well (8,9,12). Herein, we will attempt to identify specific cohorts of patients for whom CMV seropositive (and seronegative) donors are associated with the best outcomes. 3.0 STUDY POPULATION: Patients included will be all recipients of first allogeneic stem cell transplant for AML, ALL, CML, CLL, biphenotypic leukemia, lymphoma, plasma cell disorders, severe aplastic anemia and SCID between January 1, 1999 and December 31, The cohort start date was selected in order to capture patients receiving current standard antimicrobial prophylaxis vs. cytomegalovirus (e.g., preemptive or prophylactic ganciclovir) and candidal infections (e.g., fluconazole) (13); last day of cohort enrollment was selected to allow at least 1 year of follow-up for all patients. Recipients of tandem transplants will be excluded. Potential numbers of subjects are given in Table 1.

12 Not for publication or presentation Attachment OUTCOMES: Incidence of CMV infection: CMV infection as reported by transplant teams is defined as a positive antigenemia or polymerase chain reaction (PCR) assay; isolation of CMV by biopsy from visceral sites (by cultures or histology); or the detection of CMV by culture or direct fluorescent antibody (DFA) stain on bronchoalveolar lavage fluid. Incidence of acute and chronic GVHD: time to onset of grades II-IV and III-IV acute GVHD or any chronic GVHD. Treatment-related mortality (separately for leukemia, NHL, PCD): time to death without evidence of disease recurrence. This event is summarized by the cumulative incidence estimate with relapse as the competing risk. Relapse (separately for leukemia, NHL, PCD): time to onset of leukemia recurrence. Patients will be censored at death in continuous CR, second transplant or, for patients surviving in continuous complete remission, at last contact. This event is summarized by the cumulative incidence estimate with TRM as the competing risk Disease free survival (separately for leukemia, NHL, PCD): time to treatment failure (death or relapse). Patients are censored at time of last follow-up. Overall survival: time to death. Patients are censored at time of last follow-up. Causes of death: particular emphasis on the association between CMV serostatus and death from bacterial/fungal infections or respiratory causes of death. While the veracity of cause of death data may be an issue, we believe that the size of the population studied and the fact that misclassification is not likely to segregate according to CMV serostatus will be mitigating factors. 5.0 VARIABLES TO BE ANALYZED: Patient-related: - Age - Sex - Race - Ethnicity - Karnofsky performance score at transplant - Body mass index - Recipient HSV serostatus Disease-related: - Underlying disease - Disease stage - Time from diagnosis to transplantation Transplant-related: - Donor type: related vs unrelated - Donor-recipient HLA match - Donor sex - Donor age - Donor race/ethnicity

13 Not for publication or presentation Attachment 2 - Conditioning regimen: myeloablative vs reduced toxicity vs non-myeloablative - Prior autologous transplant: yes/no - Source of stem cells: BM vs PBSC - Mononucleated cell dose - CD34 cell dose - Year of transplantation - GVHD prophylaxis: with focus on T-cell depletion, both in vivo and ex vivo Post-transplant: - CMV strategies: pre-emptive vs prophylactic 6.0 DATA COLLECTION: Data sources will include records from the CIBMTR and the FHCRC. Patient data from the CIBMTR and FHCRC will be supplemented by data obtained from a questionnaire that will be submitted to the transplant centers that have contributed patients to the study population. The questionnaire will collect data regarding center-specific CMV prophylaxis strategies as they have evolved over time, including whether these strategies were different according to transplant modality. Ganciclovir strategies will be characterized as preemptive or prophylactic. For preemptive strategies, assay used for surveillance will be noted, given that differences in assay performance may impact the success of the preemptive approach (14). In addition, the schedule of ganciclovir adminstration (dose and duration of induction and maintenance therapy) will be captured for both strategies, and the post-100 day surveillance strategy will be noted as well. The use of acyclovir prophylaxis will also be captured (high dose vs. low dose vs. none intravenously before engraftment, high dose vs. low dose vs. none until day 100 and day 365 after transplant). These factors will be entered as categorical variables in the analyses noted below in order to determine whether they influence outcome after controlling for factors associated with the outcomes of interest (including center). 7.0 STUDY DESIGN: Survival and disease-free survival rates will be calculated according to the method of Kaplan and Meier and will be compared using the log rank statistic. Rates of acute and chronic GVHD, relapse, TRM, and significant infection will be presented with cumulative incidence estimates, with relapse and death considered to represent competing risks as appropriate. Cox proportional hazards models will be used to assess the association of CMV serostatus of the patient and donor with time-to-event outcomes such as mortality. CMV serostatus will be assessed in univariate and multivariable analyses with separate consideration of both patient and donor results, such that four separate groups will be analyzed (D+/R+, D-/R+, D+/R-, D-/R-). Thus, seropositive patients will not be combined with seronegatives (such as D+/R- patients), and the additional effect of donor serostatus may be assessed for both seropositive and seronegative recipients. This crucial step has been omitted in several studies in the literature (2,3,5,10), which may render their final published analyses somewhat unreliable. Step-up and step-down regression methods will be used to identify factors for inclusion in the regression models. Factors will be included either on the basis of statistical significance of if their inclusion modifies the effect of another factor in the model by more than 10%. No adjustments will be made for multiple comparisons. Due to the number of comparisons to be made, however, P values <0.01 will be viewed as significant, and P values between 0.01 and 0.05 will be viewed as suggestive. As detailed in our specific study questions above, we are particularly interested in the interaction of CMV serostatus of patient and donor with other variables. Specifically, we will explore

14 Not for publication or presentation Attachment 2 whether the receipt of an alternative donor transplant and/or T-cell depleted transplant modifies the effect of recipient or donor CMV serostatus on outcome. We will also explore whether the use of antiviral prophylaxis with either acyclovir or ganciclovir attenuates the hypothesized association of CMV seropositivity with outcome in high-risk HSCT recipients. Finally, we will attempt to define the impact of donor CMV serostatus in the context of competing donor selection criteria (including donor age, HLA match, gender/parity status) for different transplant types (Tcell depleted vs. replete, BMT vs. PBSCT, myeloablative vs. nonmyeloablative conditioning) in order to optimize the selection of stem cell donor for each transplant type. 8.0 REFERENCES: 1. Meyers JD, Flournoy N, Thomas ED. Nonbacterial pneumonia after allogeneic marrow transplantation: a review of ten years' experience. Reviews of Infectious Diseases. 1982;4(6): Broers AE, van Der Holt R, van Esser JW, et al. Increased transplant-related morbidity and mortality in CMV-seropositive patients despite highly effective prevention of CMV disease after allogeneic T-cell-depleted stem cell transplantation. Blood. 2000;95(7): McGlave PB, Shu XO, Wen W, et al. Unrelated donor marrow transplantation for chronic myelogenous leukemia: 9 years' experience of the national marrow donor program. Blood. 2000;95(7): Cornelissen JJ, Carston M, Kollman C, et al. Unrelated marrow transplantation for adult patients with poor-risk acute lymphoblastic leukemia: strong graft-versus-leukemia effect and risk factors determining outcome. Blood. 2001;97(6): Craddock C, Szydlo RM, Dazzi F, et al. Cytomegalovirus seropositivity adversely influences outcome after T-depleted unrelated donor transplant in patients with chronic myeloid leukaemia: the case for tailored graft-versus-host disease prophylaxis. British Journal of Haematology. 2001;112(1): Kroger N, Zabelina T, Kruger W, et al. Patient cytomegalovirus seropositivity with or without reactivation is the most important prognostic factor for survival and treatment-related mortality in stem cell transplantation from unrelated donors using pretransplant in vivo T-cell depletion with anti-thymocyte globulin. Br J Haematol. 2001;113(4): Castro-Malaspina H, Harris RE, Gajewski J, et al. Unrelated donor marrow transplantation for myelodysplastic syndromes: outcome analysis in 510 transplants facilitated by the National Marrow Donor Program. Blood. 2002;99(6): Nichols WG, Corey L, Gooley T, Davis C, Boeckh M. High risk of death due to bacterial and fungal infection among cytomegalovirus (CMV)-seronegative recipients of stem cell transplants from seropositive donors: evidence for indirect effects of primary CMV infection. J Infect Dis. 2002;185(3): Kollman C, Howe CW, Anasetti C, et al. Donor characteristics as risk factors in recipients after transplantation of bone marrow from unrelated donors: the effect of donor age. Blood. 2001;98(7): Meijer E, Dekker AW, Rozenberg-Arska M, Weersink AJ, Verdonck LF. Influence of cytomegalovirus seropositivity on outcome after T cell-depleted bone marrow transplantation: contrasting results between recipients of grafts from related and unrelated donors. Clin Infect Dis. 2002;35(6): Doney K, Hagglund H, Leisenring W, Chauncey T, Appelbaum FR, Storb R. Predictive factors for outcome of allogeneic hematopoietic cell transplantation for adult acute lymphoblastic leukemia. Biol Blood Marrow Transplant. 2003;9(7): Ljungman P, Brand R, Einsele H, Frassoni F, Niederwieser D, Cordonnier C. Donor CMV serological status and outcome of CMV seropositive recipients after unrelated donor stem cell transplantation; an EBMT Megafile analysis. Blood

15 Not for publication or presentation Attachment Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. Biology of Blood & Marrow Transplantation. 2000;6(6a): ; 715; Boeckh M, Boivin G. Quantitation of cytomegalovirus: methodologic aspects and clinical applications. Clin Microbiol Rev. 1998;11(3):

16 Not for publication or presentation Attachment 2 Table 1. Characteristics of patients who underwent bone marrow or peripheral blood stem cell allogeneic transplants for AML, ALL, CML, CLL, biphenotypic leukemia, lymphoma, plasma cell disorders, severe aplastic anemia and SCID between 1999 and 2003, reported to the CIBMTR, by donor-recipient CMV status prior to transplant. D+/R+ D+/R- D-/R+ D-/R- Variable: N (%) N (%) N (%) N (%) Number of patients Age, median (range), years 36 (<1-75) 34 (1-82) 40 (<1-79) 35 (<1-75) Age in decades, years < ( 9) 214 (15) 230 ( 9) 349 (12) (14) 180 (13) 305 (12) 462 (16) (16) 216 (16) 341 (13) 434 (15) (17) 249 (18) 422 (17) 500 (17) (20) 272 (20) 589 (23) 577 (20) (18) 211 (15) 512 (20) 457 (16) ( 6) 45 ( 3) 150 ( 6) 133 ( 4) Male sex 2091 (57) 871 (63) 1401 (55) 1821 (63) Race Caucasian/White 2417 (66) 1126 (81) 2117 (83) 2592 (89) Black 206 ( 6) 80 ( 6) 113 ( 4) 60 ( 2) Asian/Pacific Islander 606 (16) 84 ( 6) 146 ( 6) 79 ( 3) Hispanic 236 ( 6) 61 ( 4) 103 ( 4) 115 ( 4) Native American 25 ( 1) 5 ( 1) 10 (<1) 5 (<1) Other 142 ( 4) 23 ( 2) 38 ( 2) 30 ( 1) Unknown 28 ( 1) 8 (<1) 22 ( 1) 31 ( 1) Disease AML 1054 (29) 363 (26) 837 (33) 762 (26) ALL 592 (16) 257 (19) 430 (17) 620 (21) Biphenotypic leukemia 38 ( 1) 15 ( 1) 20 ( 1) 17 ( 1) CML 654 (18) 272 (20) 397 (15) 512 (18) CLL 100 ( 3) 25 ( 2) 75 ( 3) 90 ( 3) MDS 405 (11) 156 (11) 284 (11) 329 (11) Lymphoma 316 ( 9) 166 (12) 248 (10) 326 (11) Plasma Cell Disorders 66 ( 2) 19 ( 1) 51 ( 2) 49 ( 2) Severe Aplastic Anemia 376 (10) 64 ( 5) 177 ( 7) 183 ( 6) SCID 59 ( 1) 50 ( 3) 30 ( 1) 24 ( 1)

17 Not for publication or presentation Attachment 2 Table 1. Continued. D+/R+ D+/R- D-/R+ D-/R- Variable: N (%) N (%) N (%) N (%) Karnofsky score prior to tx < (27) 361 (26) 756 (30) 730 (25) > (70) 959 (69) 1641 (64) 2031 (70) Missing 120 ( 3) 67 ( 5) 152 ( 6) 151 ( 5) Conditioning regimen Myeloablative 2495 (68) 1041 (75) 1793 (70) 2154 (74) Non-myeloablative 829 (23) 284 (20) 635 (25) 615 (21) To be determined 248 ( 7) 40 ( 3) 86 ( 4) 110 ( 4) Missing 88 ( 2) 22 ( 2) 35 ( 1) 33 ( 1) Donor HLA-identical sibling 2004 (55) 413 (30) 685 (27) 980 (34) Other relative 246 ( 7) 86 ( 6) 79 ( 3) 94 ( 3) Unrelated 1410 (38) 888 (64) 1785 (70) 1838 (63) Donor age, median (range), yrs 37 (<1-93) 38 (2-95) 35(<1-73) 35(<1-96) Missing Donor sex Male 1980 (54) 704 (51) 1665 (65) 1875 (64) Female 1670 (46) 681 (49) 880 (35) 1035 (36) Unknown 10 (<1) 2 (<1) 4 (<1) 2 (<1) Graft type BM 1923 (53) 826 (60) 1433 (56) 1683 (58) PBSC±BM 1737 (47) 561 (40) 1116 (44) 1229 (42) Year of transplant (20) 307 (22) 492 (19) 638 (22) (20) 287 (21) 495 (19) 660 (23) (20) 268 (19) 490 (19) 548 (19) (21) 295 (21) 546 (22) 534 (18) (19) 230 (17) 526 (21) 532 (18) Median fu of survivors, months 15 (1-73) 23 (2-75) 22 (2-74) 24 (1-77) * There are 177 reporting centers for the HLA-identical sibling or related transplants.

18 Not for publication or presentation Attachment 3a CIBMTR R04-90 KIR-LIGAND: NK CELL INTERACTION AND INFECTION AFTER UNRELATED DONOR TRANSPLANTATION Study Chair: Study Co-Chairs: Jo-Anne Young, MD, FACP University of Minnesota 420 Delaware St. SE Minneapolis, MN Telephone: Fax: Marcie Tomblyn, MD, MS University of Minnesota 420 Delaware Street SE Minneapolis, Minnesota Telephone: Fax: Sarah Cooley, MD University of Minnesota 420 Delaware Street SE Minneapolis, Minnesota Telephone: Fax: Jeffrey Miller, MD University of Minnesota 420 Delaware Street SE Minneapolis, Minnesota Telephone: Fax:

19 Not for publication or presentation Attachment 3a Daniel Weisdorf, MD University of Minnesota 420 Delaware Street SE Minneapolis, Minnesota Telephone: Fax: Study Statistician: Working Committee Chairs: Michael Haagenson, MS CIBMTR 3001 Broadway Street, N.E., Suite 110 Minneapolis, MN USA Telephone: Fax: Juan Gea Banacloche, MD National Institutes of Health 9000 Rockville Pike Bethesda, MD Telephone: Fax: Jan Storek, MD, PhD University of Calgary 3330 Hospital Drive NW Calgary, Alberta, T2N 4N1 Telephone: Fax: Jo-Anne Young, MD, FACP University of Minnesota 420 Delaware St. SE Minneapolis, MN Telephone: Fax: Scientific Director: Marcie Tomblyn, MD, MS University of Minnesota 420 Delaware Street SE Minneapolis, Minnesota Telephone: Fax:

20 Not for publication or presentation Attachment 3a 1.0 HYPOTHESIS: Patients receiving cells from donors with at least one KIR B haplotype will have decreased infectious complications through enhanced NK cell function 2.0 OBJECTIVES: 2.1 To compare outcomes for patients undergoing an unrelated donor transplant and for who detailed infectious disease data were collected. Comparison groups will be based on the presence of at least one KIR B haplotype from the donor. Outcomes to be studied include: Infectious complications; Graft-vs-host disease (GvHD) at 1 year; Treatment-related mortality at 100 days; Overall survival at 1 year; Causes of death 3.0 SCIENTIFIC JUSTIFICATION: Donor derived NK cell reactivity may be an important, yet poorly recognized aspect of developing host defense accompanying allogeneic hematopoietic cell transplantation (HCT). Functional development of NK cells recovers quickest of the lymphoid subpopulations after allotransplantation, but the KIR repertoire of fully-expressed and functional KIR resembling the normal donor pattern may be delayed in development 1. Preliminary data (Miller et al.) suggests that recovery of functional KIR may be delayed in recipients with GVHD or those who received non-t depleted URD grafts. Delayed development of inhibitory KIR may yield poorly regulated NK cell function and may contribute to GVHD and other peritransplant complications. In contrast, prompt and functional NK cell development may be important components of host defense to protect against opportunistic infection in the first peri-transplant months, before T cell reactivity can be established and immunoglobulin synthesis has recovered. To our knowledge, post-transplant infectious complications in KIR-mismatched allogeneic HCT have been reported only in a single institution study 2. HLA and KIR genes exhibit independent segregation such that HLA match may result in KIR mismatch. KIR can be simplified in to biologically distinct genotypes based on the presence of a single activating KIR gene for each haplotype (A/A) versus those with the presence of multiple activating KIR genes on at least one haplotype (B/x). Cooley et al demonstrated that activating donor KIR haplotypes (B/x) improve leukemia free survival independent of recipient KIR haplotype following unrelated donor HCT (personal communication). Activating donor KIR haplotype also led to increased incidence of chronic GVHD with similar acute GVHD compared to transplant recipients from inhibitory KIR haplotypes (A/A). In renal allograft recipients, the recipients KIR haplotype was found to be important 3. In multivariate analysis, Stern and colleagues reported decreased rates of CMV infection and reactivation in patients with B/x KIR

21 Not for publication or presentation Attachment 3a haplotype compared to those with A/A haplotype [B/x: 0.34 (95% CI: ), p <0.01]. During 2003, the NMDP collected detailed infectious disease data on nearly 250 unrelated donor transplants. We hypothesize that the patients who received stem cells from donors with the activating KIR genotype (B/x) will have decreased infectious complications after HCT. 4.0 STUDY POPULATION: All consenting donors and recipients who participated in the NMDP infectious disease prospective data collection pilot project during 2003 will be included. Patients have extensive and detailed information from baseline, at two week intervals through day + 90 and then monthly through d+180. KIR genotyping of recipients and donors will be analyzed by Dr. Peter Parham and Dr. Elizabeth A. Trachtenberg to confirm presence of KIR B haplotype. 5.0 OUTCOMES: 5.1 Infection density: infections per patient per days at risk 5.2 Incidence of specific infections: bacterial, viral, and fungal 5.3 Incidence of acute GvHD: grade II-IV acute GVHD 5.4 Incidence of chronic GvHD: limited and extensive 5.5 Treatment related mortality: 5.6 Overall survival: time to death. Patients are censored at time of last follow-up. 6.0 VARIABLES TO BE ANALYZED: Patient-related: - Age by decades - Gender: male versus female - Karnofsky performance status: <90% vs 90% Infection-related: - Baseline infections: pretransplant through conditioning - Any prior fungal infections - CMV serostatus of donor and recipient Transplant-related: - HLA match vs mismatch - Source of stem cells: BM vs PBSC vs both - Recipient-donor sex match: F-M vs F-F vs M-F vs M-M - TBI (yes vs no) - Conditioning regimen: myeloablative vs reduced intensity - GVHD prophylaxis

22 Not for publication or presentation Attachment 3a 7.0 STUDY DESIGN: Patient-, infection-, and treatment-related factors will be compared between the two KIR genotypes (A/A vs B/x) using Chi-square test for categorical and Mann-Whitney test for continuous variables. Because other factors may modify the risk of infection, in addition to donor KIR B haplotype, patient s age, marrow vs. peripheral blood stem cells, disease (AML/ALL/other leukemia/mds vs Other disease), HLA matching, CMV serostatus of donor and recipient, and acute GVHD as a time dependent covariate will be used as cofactors in regression models predicting the incidence of infection (bacterial, fungal, viral, or total) with the KIR related variables included in the model. Because patients develop multiple infections over the six month period of observation, modeling of these variables in relation to infection density (infections per patient per days at risk) will also be tested for the global and organism class (bacterial, fungal, viral) groupings of infection. Probabilities of overall and disease free survival will be calculated using the Kaplan- Meier estimator, with the variance estimated by Greenwood s formula. Values for other endpoints included in Section 5.0 will be generated using cumulative incidence estimates. Comparison of survival curves for each group will be done using the log-rank test. 8.0 REFERENCES: 1. Shilling HG, McQueen KL, Cheng NW, Shizuru JA, Negrin RS, Parham P. Reconstitution of NK cell receptor repertoire following HLA-matched hematopoietic cell transplantation. Blood. 2003;101: Schaffer M, Malmberg KJ, Ringden O, Ljunggren HG, Remberger M. Increased infection-related mortality in KIR-ligand-mismatched unrelated allogeneic hematopoietic stem-cell transplantation. Transplantation. 2004;78: Stern, M, Elsasser H, Honger G, Steiger J, Schaub S, Hess C. The Number of Activating KIR Genes Inversely Correlates with the Rate of CMV Infection/Reactivation in Kidney Transplant Recipients. Am J of Transplantation. 2008; 8: 1 6.

23 Not for publication or presentation Attachment 3a Table 1. Characteristics of patients who received a bone marrow or peripheral blood stem cell transplants and have detailed infectious disease data reported to the NMDP in 2002 by donor KIR genotype. Donor KIR Genotype A/A Donor KIR Genotype B/x Variable: N Eval N (%) N Eval N (%) Number of patients P-value Number of centers Age, median (range), years (2-67) (1-66) 0.66 Age at transplant < 10 y 1 ( 2) 7 (10) y 3 ( 7) 8 (11) y 9 (20) 8 (11) y 9 (20) 13 (18) y 9 (20) 10 (14) > 50 y 13 (30) 26 (36) Male sex (57) (61) 0.65 Karnofsky prior to transplant > (57) (68) 0.45 Disease AML 14 (32) 23 (32) ALL 11 (25) 15 (21) Other leukemia 1 ( 2) 8 (11) CML 4 ( 9) 6 ( 8) MDS 6 (14) 6 ( 8) NHL 5 (11) 9 (13) Hodgkin s lymphoma 2 ( 5) 1 ( 1) Severe aplastic anemia 1 ( 2) 3 ( 4) Histiocytic disorders 0 1 ( 1) Disease status at transplant Early 10 (23) 12 (17) Intermediate 9 (20) 14 (19) Advanced 13 (30) 21 (29) Other 12 (27) 25 (35) HLA matching - matched 8/ (47) (53) 0.09

24 Not for publication or presentation Attachment 3a Table 1. Continued. Donor KIR Genotype A/A Donor KIR Genotype B/x P-value Variable: N Eval N (%) N Eval N (%) HLA-A,B,C & DRB1 groups Well-matched 24 (54) 41 (57) Partially matched 10 (23) 21 (29) Mismatched 10 (23) 10 (14) Conditioning regimen Myeloablative 33 (75) 40 (55) Reduced intensity 8 (18) 22 (31) Non-myeloablative 3 ( 7) 9 (13) Other 0 1 ( 1) Donor age, median (range), years (21-59) (19-56) 0.30 Donor age, years (23) 25 (35) (41) 20 (28) (23) 22 (30) 50 and older 6 (14) 5 ( 7) Donor/recipient sex match Male/Male 15 (34) 22 (31) Male/Female 9 (20) 18 (25) Female/Male 10 (23) 22 (31) Female/Female 10 (23) 10 (14) Donor/recipient CMV match Negative/Negative 8 (18) 21 (29) Negative/Positive 16 (36) 27 (38) Positive/Negative 11 (25) 10 (14) Positive/Positive 8 (18) 13 (18) Unknown 1 ( 2) 1 ( 1) Time from diagnosis to TX, months (1-159) ( ) 0.12 Graft type Bone marrow 24 (55) 39 (54) Peripheral blood stem cells 20 (45) 33 (46)