Blood component transfusion and immunological status of recipients. Jean-Pierre Allain University of Cambridge, UK

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1 Blood component transfusion and immunological status of recipients Jean-Pierre Allain University of Cambridge, UK

2 Main viruses considered: transmissible by transfusion and reactivating Viruses Target cell(s) Transfusion risk (%) CMV Granulocyte (monocyte) NLD LD 2-5 EBV B-cells <1 HHV-6 CD4+T-cell (monocyte)? HHV-8 B-cells 5-10 in IC patients HBV Hepatocyte B19V Erythroblast <10 5 IU/ml <5 > 10 5 IU/ml 50-60

3 Importance of immune status in TX or organ recipients Acute infection Sanctuaries: biological portfolio Recipients of TX or organ Clinical symptoms Clinical recovery By immune defences Antibodies White cells No detectable virus in circulation Lymph nodes CMV, HHV-8, EBV, HIV Liver HBV, HAV Bone marrow B19V Immunocompetent Maintain viral control Undetectable in blood Immunodeficient Age, chemo; transplant of BM or organs; HIV - Increased susceptibility to external pathogens - Reactivation of past infections ( viral load) - Severe symptoms

4 Major immunosuppressive drugs used in SOT, BMT, HSCT, Cancer, Autoimmune diseases Group Name Target Mechanism Side effects mab anti-t/b cells Anti-thymocyte globulin T-cells Destroys T-cells PTLD Basiliximab T-cells Anti-IL2Ra CD25 Viral reactivation? Daclizumab T-cells Anti-IL2Ra Viral reactivation? CAMPath Alemtuzumab T-cells & B-cells Anti-CD52 Viral reactivation Calcineurin inhibitors Ciclosporin T-cells Anti-T-cells Viral reactivation Tacrolimus T-cells Anti-IL2 Viral reactivation Sirolimus T-cells Anti-IL2 Viral reactivation Anti-B-cells Rituximab B-cells Anti-CD20 Lymphopenia Purine analog Fludarabine DNA Ribonucleotide reductase Viral reactivation & polymerase PTLD = Post Transplant Lymphoproliferative Disease

5 Main indications of immunosuppressive drugs Clinical condition Immunosuppressive drugs Frequency of use % Organ transplantation ciclosporin + AZA + cst <2000 tacrolimus + MMF + cst CAMPath + tacrolimus + cst >2005 Bone marrow Transplant ciclosporin 20 tacrolimus 80 Haematological cancer Rituximab <20 HL, NHL R-CHOP* >50 Fludarabine <10 Breast cancer Many Auto-immune disease Anti-TNF + Steroids ~100 SLE, Rh Arthr, AnkSpon * R-CHOP = rituximab + cyclophosphamide + doxorubicin + vincristine + prednisone

6 Factors contributing to SOT outcome Viral status D-R- D+R- D-R+ D+R+ Immunosuppression CsA+AZA+cst Tac+MMF+cst CAMPath+Tac+MMF+cst AV prophylaxis or preemptive Ganciclovir IV Valganciclovir PO Acyclovir Clinical outcome Graft rejection Viral reactivation/disease Other infections

7 Herpesviruses and SOT CMV HHV-6 EBV HHV-8 Ab prevalence (%) Reactivation rate (%) <5 Viral disease no AV(%) 5-20 with AV 2-5 <1 <1 14% in KT Organ failure (%) 2 Kidney 16 to 4.3 AV 0 77 Related to KS Liver 16 to 4.3 AV 7 0 Induced tumour PTLD (%) KS (%) 0-28 Prevention Gancyclovir, valganciclovir Ganciclovir? Ganciclovir Ganciclovir, Foscarnet Prophylaxis Yes D+/R-; D+/R+ No No No Preemptive D-/R+ Questionable Yes Yes 1. Viraemia after SOT without anti-viral therapy 2. Direct effect of viral infection on transplantation outcome

8 Origins of viraemia in transplantation Recipient of SOT or BMT or HSCT Virus Virus specific IgG prior to transplantation % Positive % Negative B19V HBV CMV EBV % reactivation Susceptible to infection (% risk) Community acquired Donor Transfusion B19V 31 >95 Not described <1:10,000 HBV HBsAg+ 38% (30-60) <2 Excluded HBsAg 1:100-<1/M Anti-HBc+ 3.5% (2-5) <10 NAT 1:0.5-1M CMV (8) 12 Disease D+/R- 22% NLD LD 2-5 EBV <2 8 <2

9 CMV reactivation in SOT according to chemotherapy and anti-viral prevention Immunosuppression Anti-viral % adverse event N patients Author/year Reactivation CMV disease CsA/AZT/cst None Kalil 2005 Prophylaxis Preemptive CsA/AZT.cst Prophylaxis Bataille 2010 Tac/MMF/cst Prophylaxis Tac/MMF/cst Prophylaxis Margreiter 2008 CAMPath/Tac/MMF/cst Prophylaxis Anti-IL2/CsA/cst Prophylaxis Manuel 2007 Anti-IL2/Tac/MMF/cst Prophylaxis CsA = cyclosporine; AZT = azathioprin; cst = corticosteroids; Tac = tacrolimus; MMF = mycophenolate mofetil; GCV = ganciclovir; VGCV = valganciclovir

10 HBV reactivation in drug-induced immunosuppression Type of patients IS drug AV prevention % reactivation Lamivudine 100mg/d HBsAg+ Anti-HBc+ SOT CsA, Tacrolimus (anti- No IL2), CAMPath, cst Yes < BMT ATG (anti-t-cell), CsA, No 45 Tacrolimus, CAMPath Yes 5 0 Lymphomas CHOP No 37 0 R-CHOP No 3.3 Yes 3.8 Rituximab (anti-cd20) No 60 Yes 13 Auto-immune dis Anti-TNF No Yes 2.2 CsA = ciclosporin; ATG = anti-thymocyte globulin; CHOP = Cyclophosphamide+doxorubicin+vincristine+prednisone; R = Rituximab

11 Reactivation of HBV 29 years after acute HBV recovered infection (Power et al, J Hepatol 2010;53:780-5) 60y Male with CLL Acute HBV sexually transmitted HBV vaccination HBV acute infection Chlorambucil Fludarabine Transfusions 300 exposures Anti-HBc Anti-HBs HBsAg HBV DNA ALT 308 IU/L

12 Reactivation of HBV 29 years after acute HBV recovered infection (Power et al, J Hepatol 2010;53: 780-5) 60y Male with CLL Acute HBV sexually transmitted HBV vaccination HBV acute infection Chlorambucil Fludarabine Transfusions 300 exposures Anti-HBc Anti-HBs HBsAg HBV DNA ALT 308 IU/L

13 AY090457H AY090454H X75658F X69798F ABO36920F AB036910F X75663F U9551D P R (08-09) D D (08-08) P R (02-10) R (05-10) P R (11-09) BZ D (06-10) R (07-10) M32138D Z35716D X02496D AB091256E AB091255E X75664E AB106564E X75657E AB194949A3 AB194950A3 M57663A AY233290A AY934772A AY934773A S50225A2 X70185A2 Z35717A AY233286A Z72478A2 AB116077A2 V00866A2 AB056515G AB056513G AB064311G M54923B D23678B 0.01 D50522B M38636C D23680C D50519C Phylogenetic tree of 2 donor and 5 recipient HBV strains involved in transfusion-transmission from an OBI donor (Dr I. Mihaljevic, Zagreb, Croatia) 0.01

14 B19V and transfusion-transmission Prevalence of acute infection in donors: 1: 5,000-15,000 with VL IU/ml Prevalence of persistent infection: % with VL <10 5 IU/ml Factors considered: Serostatus donors; viral dose transfused; serostatus and immune status of recipient Risk factors Donor Recipient Susceptibility to infection Susceptible (B19V IgG-) Not susceptible (IgG+) Status unknown Adults = 10-75% IgG positive IgG neg (IgM±) Children = % Carriage of B19 DNA Persistent Acute/recent VL <10 4 IU/ml VL >10 4 IU/ml Infectious dose <10 5 IU 0/24 (0%) 0/13 (0%) N=30 no infection!10 5 2/2 (100%) 1/1 viremic N=18 9 infections (50%) Immune status Competent Deficient Known or unknown 3/18 (17%) 4/27 (15%) Immunodeficient 0/13 (VL<10 5 IU) Compilation from: Plentz Transfusion 2005, Parsyan Transfusion 2006, Kleinman Blood 2009, Yu Transfusion 2010, Hourfar Transfusion 2011, Satake Transfusion 2011

15 Reactivation of B19V in kidney transplant recipients (Park J et al, Transpl Intern 2008) Probable transfusion-related infection Reactivation

16 B19V reactivation in kidney transplantation (Cavallo et al J Clin Virol 2003) Recipient status pre-tplt IgG+/DNA+ IgG+/DNA- IgG-/DNA- 1 (2.1%) 46 (95.8) 1 (2.1) Donor B19V IgG IgG + IgG+ IgG - IgG Recipient B19V DNA post-tplt (donor infection) % reactivation 21.3 Role of immunosupressive drugs N DNA + (%) CsA + AZA + cst 21 3 (14.3) CsA + cst 7 2 (28.6) CsA + MMF + cst 6 0

17 B19V in Liver Tplt and BMT in UK and Poland (Gobbini et al in preparation) 65 Liver transplantation 51 BMT/HSCT B19V IgG (%) Positive 48 (74) Negative 17 (26) Positive 40 (78.4) Negative 11 (21.6) DNA pos 1 (1.5) 0 Immunosuppressive drugs Tacrolimus + AZA + cst + + Tac + cst (UK) + + CsA + cst (Pol) + + Anti-viral prophylaxis Gancyclovir + IgG Gancyclovir + IgG Acyclovir (Gan or foscarnet) Acyclovir Donor status unknown Post-transplantation status B19V DNA + (%) Anti-B19V 3 (passive transfer) 4 (1Tx, 3 passive)

18 Impact of HIV on HBV and herpesviruses

19 Immunocompetence and age Compston et al % viraemia N=80 Virus Plasma Cellular fraction P value 20-60y > y >68 B19V HBV GBV-C CMV <0.001 EBV <0.001 HHV VZV 0 0

20 Conclusions Approximately 50% of blood product recipients are ID Immunodeficiency causes common viruses to reactivate Immunosuppressive drugs and cancer chemotherapy cause ID Monoclonal Ab and drugs anti-t-cells cause highly effective ID Reactivated viruses affect transplanted organs and may cause PTLD Anti-viral prophylaxis or preemptive therapy is largely effective Transfusion-related viral infection is rare but needs to be excluded Storage of donor and recipient whole blood samples can be critical

21 Role of 6 variables in OBI infectivity by transfusion (Allain et al, submitted) Factor Estimate Risk factor Std Error P-value Anti-HBs (donor) * Vaccination (recipient) Product transfused ** Viral dose (IU/ml) In absence of anti-hbs 0.003** Immunodeficiency * indicates P<0.05; ** indicates P<0.01

22 Screening algorithm Multiplex real-time PCR Single virus QPCR B19V / HBV/ HHV-8 EBV / CMV/ VZV HAV/ HEV No QPCR signal for specific viruses Yes Sample negative for specific virus Single virus QPCR Viral load quantification Final viral load result (>50 copies) Yes 50 copies Nested-PCR No undetectable Confirmation of 50 copies Sample negative for specific virus

23 EBV reactivation and immunosuppression

24 Levels of immunodeficiency in blood recipients Minor - Elderly Major short term - Autologous BMT - Cancer chemotherapy Major longer term - Neonates - Allogeneic BMT - Organ transplantation - Congenital immunodeficiencies - HIV infection

25 Severe transfusion transmitted parvovirus B19 infection in kidney transplant recipient (Brodin-Sartorius 2010) Donation 1E9 IU/ml IVIg, intravenous immunoglobulin; ATG, anti-thymocyte globulin; CS, corticosteroids; FK506, tacrolimus; MMF, mycophenolate mofetil; IgM, immunoglobulin M; IgG, immunoglobulin G; PB19, parvovirus B19; cop, copies.

26 Transfusion of B19V-infected RBC to a seropositive immunocompetent recipient (ARC NC) Recipient Donor B19V DNA (IU/ml) B19V IgG (S/CO) Days Days post transfusion

27 Pathogenicity and immune status Virus Pathogenicity Disease Immunocompetent Immunodeficient HHV KS, CD, BCL CMV +/- +++ Hepatitis, pneumopathy thrombocytopenia HTLV-I - ++ TSP, ATL WNV +/- +++ Meningoencephalitis B19V +/- ++ Chronic anaemia HBV in adults +/- ++ Fulminant hepatitis Chronic infection

28 Assay development or use 1. Screening multiplex NATs HBV-HHV8-B19V CMV-EBV-HZV HAV-HEV-GBV-C 2. Confirmatory single virus quantitative Real-time PCR for 9 viruses 3. Nested PCR (RT-PCR) and sequencing 4. Commercial ELISA to screen for antibodies specific to each virus

29 Impact of immune status on CMV chronic infection Authors Condition % reactivation 1 CMV disease 2 Fassas 2000 BMT Tomonari 2002 CB BMT 79 5 Junghanss 2003 SC BMT 68 9 Foot 1998 BMT CMV antigenaemia /58 fatal (14%) 3. Allogeneic unrelated

30 Background seroprevalence and frequency of viraemia in the Ghanaian blood donor population % Positive Viraemia Ab Virema VZV CMV EBV HHV-8 HBV B19 GBV-C HAV Virus

31 Clinical circumstances of immunodeficiency Natural Therapeutic - Congenital agammaglobulinaemia - HIV infection - Solid organ transplantation (SOT) - Bone marrow transplantation (BMT) - Haemopoietic stem cell transplantation (HSCT; UCB) - Haematologic cancer (Hodgkin, non-hodgkin lymphoma) - Cancer (breast and other) - Auto-immune diseases

32 Clinical case from Cork, Ireland Power et al, J Hepatol 2010;53: Male 60 years old CLL in 2001 HBV vaccine April 03 Pancytopenia Sepsis Tx 300 donor exposures Intermittent Chlorambucil Intermittent Fludarabine 4/04 10/04 Acute HBsAg Neg Pos Hep B HBeAg nd Pos Anti-HBc Pos Pos Anti-HBs nd Pos

33 Importance of viral immunological control Power et al, J Hepatol 2010;53: Sexual transmission Develop leukaemia Chemotherapy Acute Hepatitis B infection HBV vaccine Multiple transfusions Acute Hepatitis B Anti-HBs = recovery 25 year persistence Immunosuppression = reactivation Mutant selected = replication = acute hepatitis

34 Phylogenetic tree of 1124 nt Pre-S/S region Genotype D M32 AY72 Unrelated Index X02 Related infection AY233 Genotype C CX75 Genotype B BX97 Genotype A AZ72t 0.01 substitutions/site