Treatment of HIV and acute myeloid leukemia by allogeneic CCR5-d32 blood stem cell transplantation Elena Knops
Background - the Berlin patient so far the only person presumed to be cured from HIV by hematopoietic stem cell transplantation (HSCT) from a homozygous CCR5-d32 donor
Background - the Berlin patient so far the only person presumed to be cured from HIV by hematopoietic stem cell transplantation (HSCT) from a homozygous CCR5-d32 donor - failed attempts to reproduce cure by HSCT - viral rebound or death due to underlying malignancy
The whole story (drama in 5 acts) 48y old patient, alive, well and undetectable for HIV (RNA/DNA) over 4 years after allogeneic CCR5-d32 HSCT
The beginning (prologue) induction consolidation
The beginning (prologue) induction consolidation AML diagnosis in Jan 2011
The beginning (prologue) induction consolidation complete remission of AML
The beginning (prologue) induction consolidation to avoid interactions with chemotherapy TDF/FTC/RAL
Chapter I September 2012 female donor, 2 cycles high-dose cytarabine 10 out of 10 HLAmatched CCR5-d32...... one week before SCT
Chapter I stem cells from female, 10/10 HLA-matched CCR5-d32 donor...... one week before SCT
Chapter I...... one week before SCT
Chapter I...... one week before SCT
Chapter II during transplant and until today on ART...
Chapter II June 2013 total of 8 courses of 5-azacytidine + 4 donor lymphocyte infusions...
Chapter III + CMV, HHV8, HSV 10 0 10 0 10 0...... 2017 <LOD (884250) in rectal and ileum biopsy
Chapter III + CMV, HHV8, HSV 10 0 + increased liver values 10 0 10 0...... 2017 <LOD (884250) in rectal and ileum biopsy
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids 10 0 10 0 10 0...... 2017 <LOD (884250) in rectal and ileum biopsy
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids...... 2017 <LOD (884250) in rectal and ileum biopsy
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids... <LOD (884250) in rectal and ileum biopsy
Chapter III + CMV, HHV8, HSV Tacrolimus + topical steroids... - PBMCs - rectal + ileum - bone marrow - CSF
Chapter III Tacrolimus + topical steroids ABC/3TC/DTG <20 <20... 505 318 2016 2017 <LOD (884250) in rectal and ileum biopsy <LOQ (15 Mio) 1/20 repl <LOQ (10 Mio) 1/10 repl <LOQ (10 Mio) <LOQ (3,8 Mio) 52 month after SCT
Chapter V month after SCT 39 40 41 42 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddpcr or qpcr, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddpcr) 6.7cop/10 6 cells T EM : 0.36 Mio cells (qpcr) 5 cop/10 6 cells
Chapter V month after SCT 39 40 41 42 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddpcr or qpcr, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddpcr) 6.7cop/10 6 cells T EM : 0.36 Mio cells (qpcr) 5 cop/10 6 cells G. Dunay, Hamburg: Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers
Chapter V month after SCT 39 40 41 42 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddpcr or qpcr, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddpcr) 6.7cop/10 6 cells T EM : 0.36 Mio cells (qpcr) 5 cop/10 6 cells G. Dunay, Hamburg: Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers ICISTEM (J. Martinez-Picado & M. Salgado, Barcelona): qvoa: 23 Mio CD4 + T cells negative (IUPM < 0.031/10 6 CD4 T cells) Ileum biopsy: 0.007 Mio CD45+ cells negative (<143/10 6 CD45+ cells) Rectum biopsy: 0.0297 Mio CD45+ cells negative (<34/10 6 CD45+ cells)
Chapter V month after SCT 39 40 41 42 2016 Mar Apr May Jun ICISTEM (M. Nijhuis, Utrecht): HIV LTR-DNA not detected in >2 Mio PBMCs via ddpcr or qpcr, but positive signals in T-cell subsets: T CM : 0.2 Mio cells (ddpcr) 6.7cop/10 6 cells T EM : 0.36 Mio cells (qpcr) 5 cop/10 6 cells G. Dunay, Hamburg: Ileum biopsy: 0.1 Mio cells measured: 1/4 replicates positive with LTR-, but negative with gag primers ICISTEM (J. Martinez-Picado & M. Salgado, Barcelona): qvoa: 23 Mio CD4 + T cells negative (IUPM < 0.031/10 6 CD4 T cells) Ileum biopsy: 0.007 Mio CD45+ cells negative (<143/10 6 CD45+ cells) Rectum I. biopsy: Hauber, Hamburg: 0.0297 Mio CD45+ cells negative (<34/10 6 CD45+ cells) mvoa: negative in plasma, negative in histology
Chapter V Rag#1DD hu-cd3 HIVp24Ag Spleen Liver LN I. Hauber, Hamburg: mvoa: negative in plasma, negative in histology
Chapter V PHENOTYPIC CO-RECEPTOR TROPISM ANALYSIS (sample before transplantation, PBMC) # sequencing genotypic prediction phenotypic analysis in Tcells Clone gp120-v3 amino acid sequence reads FPR (%) Magi (R5/X4) MT2 (X4) D1 CTRPNNNTREGIHIGPGRAFFTTGEIIGNIREASC 4 95,78 R5 R5 D2 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIKEAYC 2 95,64 R5 R5 D3 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIGEAYC 2 95,64 R5 R5 D4 CTRPNNNTRKGIHIGPGRAFFTTGEIIGNIREASC 2062 77,33 R5 R5 D5 CTRPNNNTRKGITIGPGRAFFTTGEIIGDIRQAHC 4886 30,67 R5 R5 D6 CTRPNNNTRKGIHIGSRKAFFTTGGIIGDIRQAYC 2 10,61 R5/X4 X4 D7 CTRPHTNTRKRIHIGPGRAFFTTGEIIGDIRQAYC 7 1,74 R5/X4 X4 D8 CTKPNNNTRKRIHIGPGRAFFTTGEIIGNIRQASC 2 1,74 R5 R5 D9 CTRPNNNIRKRIHIGPGRAFFTTGEIIGNIREAYC 3 1,16 R5/X4 X4 HxB2V3Bal control R5 51,8 R5 R5 HxB2 control X4 0 X4 X4 Monique Nijhuis, Utrecht, ICISTEM
Chapter V CO-RECEPTOR TROPISM (sample before transplantation, PBMC) # sequencing genotypic prediction phenotypic analysis in Tcells Clone gp120-v3 amino acid sequence reads FPR (%) Magi (R5/X4) MT2 (X4) D1 CTRPNNNTREGIHIGPGRAFFTTGEIIGNIREASC 4 95,78 R5 R5 D2 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIKEAYC 2 95,64 R5 R5 D3 CTRPNNNTRKSIHIGPGRAFFTTGEIIGNIGEAYC 2 95,64 R5 R5 D4 CTRPNNNTRKGIHIGPGRAFFTTGEIIGNIREASC 2062 77,33 R5 R5 D5 CTRPNNNTRKGITIGPGRAFFTTGEIIGDIRQAHC 4886 30,67 R5 R5 D6 CTRPNNNTRKGIHIGSRKAFFTTGGIIGDIRQAYC 2 10,61 R5/X4 X4 D7 CTRPHTNTRKRIHIGPGRAFFTTGEIIGDIRQAYC 7 1,74 R5/X4 X4 D8 CTKPNNNTRKRIHIGPGRAFFTTGEIIGNIRQASC 2 1,74 R5 R5 D9 CTRPNNNIRKRIHIGPGRAFFTTGEIIGNIREAYC 3 1,16 R5/X4 X4 HxB2V3Bal control R5 51,8 R5 R5 HxB2 control X4 0 X4 X4 Monique Nijhuis, Utrecht, ICISTEM
The end? (epilogue) More assays to be done: - qvoa + ultra microchimerism (ICISTEM: M. Salgado, Barcelona): lymph node (planned) - T-cell response assay (T. Harrer, Erlangen): PBMCs from donor (in progress) - proviral DNA load from further PBMC samples and lymph node (Institute of Virology, Cologne and others) - International collaboration to guide and investigate the potential for HIV cure by stem cell transplantation. The ICISTEM project is supported by amfar Research Consortium on HIV eradication (ARCHE) Research Grant # 108930-56-RGRL www.icistem.org
Thanks to our group Institute of Virology, University of Cologne Rolf Kaiser Eva Heger Veronica Di Cristanziano Maria Neumann-Fraune Eugen Schülter Claudia Müller Saleta Sierra-Aragon Sascha Hasheminasab Institute for Immunogenetics, Kaiserslautern Martin Däumer, Alex Thielen University of Düsseldorf Hepatology & Infectiology Björn Jensen Falk Hüttig Dieter Häussinger Virology Nadine Lübke Haematology Guido Kobbe Moleculare Medizin Philipp Lang Junnat Hamdam Heinrich Pette Institut HH Ilona Hauber, Gabor Dunay, Johanna Eberhard, Silke Kummer, Julian Schulze zur Wiesch Med 3, University of Erlangen Thomas Harrer IciStem project Annemarie Wensing, Javier Martinez-Picado, Monique Nijhuis et al. MPI of Informatics, Saarbrücken Thomas Lengauer, Joachim Büch, Nico Pfeifer, Alejandro Pironti, Prabhav Kalaghatgi
Thanks to the Duesseldorf patient
Intermezzo gp160 gp120 p68 p55 gp41 p34 p25 p18 pos. control neg. control 02/2013 before SCT 06/2014 02/2015 07/2015 12/2015 01/2016