CMV INFECTION IN KIDNEY TRANSPLANTATION

CMV INFECTION IN KIDNEY TRANSPLANTATION PIERRE MERVILLE CHU BORDEAUX - UNIVERSITÉ BORDEAUX SEGALEN UMR-CNRS 5164

SUMMARY: 1.Epidemiology in kidney transplantation 2.T T cell response: αβ and γδ lymphocytes 3.CMV monitoring: Why? How? Should I? 4.Indirects effects: Clinical impact 5.Update on CMV guidelines 6.Perspectives

AT THE ERA OF GENERALIZED PREVENTION, THE RISK OF INFECTION DEPENDS ON THE TREATMENT Universal Prophylaxis Preemptive Therapy Whole blood CMV qpcr D0 M3 M6 M12 Whole blood CMV qpcr: 1/week J0-M3, 1/month M3-M12 No threshold for anti-cmv therapy

MORE CMV INFECTIONS WITH THE PREEMPTIVE STRATEGY qpcr PRO 6 Mths D+R- D+R+ D-R+ n PRO 3 Mths PREE PRO PREE PRO PREE Khoury, 2006 44,0 54,0 18,0 54,0 27,0 75,0 98,0 Kliem, 2008 52,0 74,0 10,0 56,0 0,0 25,0 148,0 Reischig, 2007 75,0 83,0 56,0 96,0 60,0 86,0 70,0 Helentera, 2010 37,0 127,0 Humar, 2010 37,4 50,9 326,0 Van der Beek, 2010 52,0 69,0 78,0 Couzi, 2012 34,0 60,0 112,0 Witzke, 2011 15,6 53,8 3,6 22,2 296,0 Atabani, 2012 70,0 53,0 44,0 368,0 Mean (%) 37,2 51,3 68,3 24,9 62,6 22,7 50,4 1623,0 PRO : Prophylactic PREE: Preemptive

SIMILAR INCIDENCE OF CMV DISEASES qpcr PRO 6 Mths D+R- D+R+ D-R+ n Proph 3 Mths PREE PRO PREE PRO PREE Khoury, 2006 19,0 8,0 5,0 0,0 0,0 0,0 98,0 Kliem, 2008 148,0 Reischig, 2007 9,0 6,0 13,0 0,0 0,0 0,0 70,0 Helentera, 2010 34,0 127,0 Humar, 2010 16,1 36,8 326,0 Van der Beek, 2010 0,0 0,0 78,0 Couzi, 2012 16,0 26,0 112,0 Witzke, 2011 4,4 19,2 3,6 5,6 296,0 Atabani, 2012 32,5 2,5 0,9 368,0 Mean (%) na 20.2 18.1 7,5 5,4 1,2 1,6 1623,0 PRO : Prophylactic PREE : Preemptive Na : Not applicable

DOMINATE THE MEMORY COMPARTMENTS OF EXPOSED SUBJECTS 70 % of viral peptides are able to generate a T cell response Sylwester et al, J. Exp. Med., 2005; 5: 673-685

IN R+ INDIVIDUALS, ANTI-CMV RESPONSE ENGAGES 4-5 % OF TOTAL CD4 AND CD8 LYMPHOCYTES Sylwester et al, J. Exp. Med., 2005; 5: 673-685

CONSEQUENCES OF CMV INFECTION: MEMORY INFLATION AND IMMUNE SENESCENCE? «CMV would represent the most important agent of effector T cell expansion and probably one of the most important causes for persistent immune activation in human aging» Vescovini et al, J. Immunol., 2007; 179: 4283-4291

γδ T CELL : A LYMPHOID STRESS SURVEILLANCE INVOLVED IN CMV INFECTION CMV Organ recipients CMV-driven expansion of γδ T cells % γδ T lymphocytes 20 15 10 5 0 CMV+ CMV- 2 4 6 8 10 12 Months post-tx Innate-like features massive expansion of Vδ2 neg cells diverse TCR repertoire high expression of MHC-NKR high expression of CD16 (JCI, 1999) MCMV Early γδ expanders Late γδ expanders Adaptive-like features Week of infection 20 16 12 8 4 0 p<0.0001 very specific of CMV associated to infection resolution long-term blood signature of CMV TEMRA phenotype, concomitant to αβ expansion more rapid response in secondary infection (JID, 2001; Blood, 2008; JID, 2009, Blood 2012) Mouse model γδ protect αβ- mice from death γδ control virus (JEM, 2005; JASN, 2010; Cancer Res, 2009)

CMV INFECTION, A RELEVANT MODEL TO UNDERSTAND γδ T CELLS STRATEGY TO IDENTIFY NEW γδ TCR LIGANDS Patients Isolated T cell clones Reporter cell lines CMV TCR γδ TCR transfer Lentiviral transduction TCR-Ligand JRT3 CD69 mab screening TCR ligand identification stress stress CMV-infected or tumor cells Immunisation

DISCOVERY OF EPCR AS THE LIGAND OF THE CLONE LES LES (Vγ5V 5Vδ5) 5) Immunoprecipitation with 2E9 and M/MS EPCR Phospholipids 75 50 37 25 20 Response (RU) 2E9+ line IgM 2E9 2E9- line (B Willcox s team) IgM 2E9 Endothelial Protein C Receptor EPCR sepcr directly binds to LES stcr 800 600 400 200 EPCR 0-60-40-20 0 20 40 60 80 TCR LES TCR MAU TCR αβ None Kd = 100 µm Time (s) Involved in coagulation (activator of protein C) α1 MHC-I-like molecule α2 Crystallization: associated with phospholipids expressed on endothelial cells (CMV targets) Increased expression on carcinoma cells α1 CD1d α2 (Willcox et al, Nat Immunol 2012) Antigen-presenting molecule Glyco- and phospho-lipid presentation to invariant NKT cells

WHY TO MONITORE SPECIFIC CMV IMMUNE RESPONSE? Prophylaxis of CMV infection : D+/R- patients : Which patients require a prolongation of prophylaxis? R+ patients : Is a treatment necessary for all patients? Treatment of CMV disease : Should we treat minor/transitory ADNemia? Following complete treatment of CMV disease, which patients require viral monitoring? When this patient is really cured?

HOW TO MONITORE SPECIFIC CMV IMMUNE RESPONSE? From Sester M, J Lab Med 2008;32:121-130. = quantiferon

SUMMARY OF THE STUDIES Assays Correlation with ADNemia Correlation with disease Clinical impact on treatment decision QuantiFERON-CMV (N=4) Yes Yes No data ELISPOT (N=5) Yes Yes No data Cytométry (N=9) Yes Yes No data Multimer HLA (N=1) No No No data - Limited number of patients (10-134), heterogeneous (R+ and D+R-) - No clear predictive threshold, weak sensitivity, influence of treatment - Probably more a matter of kinetics of the response than an immune threshold. Control Rechute

INDIRECT EFFECTS OF CMV INFECTION Infection (D+R-) Or Reactivation (R+) Fishman, NEJM, 2007 ; 357: 2601-14 CMV infection (DNAemia) DIRECT effects CMV disease INDIRECTS effects of CMV Opportunistic infections PTLD CMV Syndrome Invasive disease Hepatitis Colitis, Pneumonia, Rejection IF/TA Graft survival Arterial stenosis Patient survival Etc,

CMV AND ACUTE REJECTION : AN OLD DEBATE PRO : Sagedal S, et al. The impact of cytomegalovirus infection and disease on rejection episodes in renal allograft recipients. Am J Transplant. 2002;2(9):850-6. Toupance O, et al. Cytomegalovirus-related disease and risk of acute rejection in renal transplant recipients: a cohort study with case-control analyses. Transpl Int. 2000;13(6):413-9. Reischig T, et al. Valacyclovir prophylaxis versus preemptive valganciclovir therapy to prevent cytomegalovirus disease after renal transplantation. Am J Transplant. 2008;8(1):69-77. Lowance D, et al. Valacyclovir for the prevention of cytomegalovirus disease after renal transplantation. International Valacyclovir Cytomegalovirus Prophylaxis Transplantation Study Group. N Engl J Med. 1999;340(19):1462-70. Dickenmann MJ, et al. Cytomegalovirus infection and graft rejection in renal transplantation. Transplantation. 2001;71(6):764-7. Pouteil-Noble C, et al. Cytomegalovirus infection--an etiological factor for rejection? A prospective study in 242 renal transplant patients. Transplantation. 1993;55(4):851-7. CONTRA : Couchoud C, et al. Cytomegalovirus prophylaxis with antiviral agents in solid organ transplantation: a meta-analysis. Transplantation. 1998;65(5):641-7. Erdbruegger U, et al. Impact of CMV infection on acute rejection and long-term renal allograft function: a systematic analysis in patients with protocol biopsies and indicated biopsies. Nephrol Dial Transplant. 2012;27(1):435-43. Drawbacks : Retrospective studies Timing between CMV and acute rejection Interplay between these two major events in kidney transplantation

EFFECT OF CMV VIREMIA ON SUBCLINICAL ACUTE REJECTION AND IFTA Patients and methods : 118 kidney transplant recipients with Prophylactic treatment (VACV 3 months) Preemptive treatment (VGCV) Protocol biopsy at M3 Résults : DNAemia incidence : 41 % Subclinical acute rejection : 29 % IFTA : 28 % Subclinical acute rejection : Is not associated to DNAemia IFTA Is associated to DNAemia > 2000 copies (OR: 3.8, p=0.02) Reischig et al, Transplantation 2009; 87:436-444

SOME YEARS LATER LATE EFFECTS OF A PREEMPTIVE TREATMENT Patients : Preemptive (VGCV) : N=34 Preventive (VACV 3 mois) : N=36 Better patient survival in the preemptive group With less late-onset CMV infections Trend to less IFTA in the preemptive group (19 % vs 38 %) Reischig et al, J Am Soc Nephrol 2012 23: 1588

EFFECT ON DNAEMIA ON GRAFT DYSFUNCTION AT 2 YEARS N=55 pediatric kidney transplants 22 % of subclinical CMV DNAemia during the first two years Prophylactic treatment for 3 à 12 months More IFTA on protocol biopsies in viremic patients Unless the prophylactic treatment Smith et al, J Am Soc Nephrol 2010, 21: 1579 1586.

INDIRECT EFFECTS AT THE LIGHT OF ECOLOGICAL IMMUNOLOGY: CONCEPT OF TOLERANCE TO A PATHOGEN For each individual, a CMV infection has a fitness cost : Damage caused by the pathogen : direct effects Damage caused by host immune system : indirect effects Tolerance is the magnitude of these direct and indirect effects In transplantation, immunosuppressive treatment can differently modulate the level of tolerance Ruslan Medzhitov, Disease Tolerance as a Defense Strategy, Science, 2012, 335, 936 Ayres and Schneider, Tolerance of Infections, Ann Rev Immunol 2012, 30:271-294

CMV MANAGEMENT FROM CONSENSUS TO CLINICAL PRACTICE International consensus guidelines on the management of cytomegalovirus in solid organ transplantation Transplantation Society International CMV Consensus Group. Transplantation. 2010 Apr 15;89(7):779-95 Update October 2012

MANAGEMENT OF CMV INFECTION CONSENSUS RECOMMENDATIONS I Both universal prophylaxis and pre-emptive strategies are viable approaches for prevention of CMV disease (D+R- and R+). For centers or patients unable to meet the stringent logistic requirements required with a pre-emptive therapy strategy, prophylaxis is preferred. Where possible, 6 months may be preferable for D+/R- kidney recipients When a prophylaxis strategy is used for prevention in R+ patients (with either D+ or D-), 3 months of antiviral medication should be used When a pre-emptive therapy strategy is used, a sufficiently low threshold for initiation of treatment during pre-emptive therapy is recommended.

MANAGEMENT OF CMV INFECTION CONSENSUS RECOMMENDATIONS II Anti-viral medications used in kidney transplant: valganciclovir, intravenous ganciclovir, or high dose valacyclovir. Treatment of rejection (ALG, high dose steroids) should result in reinitiation of prophylaxis or pre-emptive therapy for 1 to 3 months The routine use of the hybrid strategy is not recommended at this time in any risk group Immune monitoring assays should continue to be improved for ease of use and standardization. Kotton CN, et al. Transplantation 2010; 89:779-795.

PERSPECTIVES WHO international standard +++ (UI/ML) Clinical studies on immune monitoring are required Maribavir and new medications (letermovir, cyclopropavir, CMX001) useful in anti-viral resistance Vaccines (anti-gb), humanized anti-cmv antibodies Modulation of immunosuppression: antiviral effects of mtor inhibitors.

MERCI POUR VOTRE ATTENTION