CMV in Organ Transplantation – - PowerPoint Presentation

Slide1

CMV in Organ Transplantation – What do I need to know?

Jay A. Fishman, M.D.Massachusetts General Hospital and Harvard Medical SchoolBoston, MA, USA

Slide2

Viruses may be dangerous . . . .

Slide3

Key Concepts

Broad array of potential pathogens in transplant recipientsSpecific microbiologic diagnosis is essential for optimal therapy and to avoid toxicitiesCytomegalovirus remains a major pathogen Most often fever and low(er) white blood cell count (“Viral syndrome”)Direct and Indirect effects of infectionGuidelines for management exist (ask Transplant ID!)Prevention (prophylaxis) of infection is linked to risk CMV: D+/R-Colonization/Leaky immunity (yes, please ignore sputum and urines) Yes, we are starting to know how it works!  Biology

Slide4

Cytomegalovirus

Betaherpesvirinae subfamily of the HerpesviridaeThe structure :Nucleus containing the viral genome (linear double-stranded DNA) Icosahedral protein capsid>200 genes with significant variationThe tegument protein matrix (e.g., pp65):Proteins with structural roles Proteins which modulates the immune host cell responseAn outer envelope derived from the host cell nuclear membrane. Glycoprotein gB - involved in cell attachment and penetration Glycoprotein gH- involved in the fusion of the viral envelope with the host cell membrane

Pérez-Sola, M.J. et al. EIMC2008;26(1):38-47

Crough T et al. Clin Microb Rev, Jan 2009, 76-98

Slide5

Risk factors for CMV disease in solid-organ transplant patients

Primary infection (D+/R−) Transplanted organs, cells Blood products Factors favoring CMV reactivation Inflammation/Fever (cytokines) Surgery/Trauma Intraoperative hypothermia Sepsis or severe bacterial infections T-cell depletion Co-infections with other viruses Herpes virus 6 or 7 (HHV6 or 7)

Factors favoring progression to invasive disease Immunosuppression T-cell depletion Mycophenolate, azathioprine Methylprednisolone boluses Alemtuzumab High viral load Immunomodulation Herpes virus 6 (HHV6) or HHV7 Genetic factors Mutations in TLR2 and TLR4 genes Deficiency of mannose-binding lectin or genotype associated with low production of MBL

Modified from GESITRA-SEIMC/REIPI recommendations for the management of CMV

infection in solid-organ transplant patients,

Enferm

Infecc

Microbiol

Clin

. 2011

Slide6

CMV SyndromeFeverWeaknessMyalgiaArthralgiaMyelosuppression

End Organ DiseaseNephritisHepatitisCarditisColitisPneumonitis RetinitisEncephalitis

CMV disease

Latent CMV infection

Active CMV infection (viremia and in tissue)

ALG, Fever, TNF

, Sepsis, Suppression

Atherosclerosis

Bronchiolitis obliterans

Vanishing bile duct syndrome

Opportunistic infection

Systemic immune suppression

Acute

Chronic

Acute

Cellular effects:

antigen and cytokine expression

EBV-associated PTLD

Allograft injury

Allograft rejection

Fishman JA & Rubin RH

N

Engl

J Med.

1998; 338: 1741

Slide7

CMV replication and release

Pathways for CMV reactivation from latency: More late disease with antibody induction?

Reinke P et al. Transplant Infect Dis 1999; 1:157-64.

TNF-



NF-

B

Stress

catechols

Pro-inflammatory prostaglandins

cAMP

EI CMV

Anti-T-cell antibodies

Slide8

CMV Disease – Need to know

CMV Viremia (no symptoms) or low grade fever

CMV Syndrome - Viremia

Fever,

Myalgias

, Neutropenia, Lymphadenopathy

End Organ Disease

Can affect any organ, especially graft

Special Sites – disease without detected viremia

Gastrointestinal tract

CNS (including eye)

Testes

Slide9

Disseminated CMV

Liver

Lung

Kidney

Colon

Slide10

CMV Retinitis: Lung Transplant Recipient

Slide11

CMV cecal ulceration in patient with negative antigenemia and PCR assays for CMV

Slide12

Rate of CMV Disease: D+/R- (Highest Risk)

Gane

et al

.

Lancet

. 1997;350:1729.

Humar

et al

.

Am J Transp

. 2005; 5:1562.

Lowance

et al

.

N

Eng

J Med

. 1999; 340:1462.

Paya

et al

.

Am J Transp

. 2004;4:611. Macdonald

et al

.

JHLT

. 1995;14:32.

Slide13

CMV in D–/R– Recipients (Low Risk)

Incidence ~2.5%

Usually from

De novo

infection

often children in household

Blood products (4% from leukocyte reduced blood)

Always confirm status if it doesn’t make sense

False negative results in donor or recipients

Slide14

CMV: Immune Response

Innate Immune Response

NK Cells

TLR2, TLR4

Mannose binding

lectin

deficiency

Adaptive Immune Response

CD4+ T cells

CD8+ T cells

B Cells & antibody production

neutralizing antibodies target

gB

and

gH

, presence of antibodies may limit dissemination of CMV although clinical significance is debatable

Slide15

CMV Immunity: Detection

l

Slide16

CMV Diagnostics

Hybrid capture Detects CMV DNA in leukocytesAmplified signalPathology

Slide17

CMV Diagnostics: PCR

Peng

et al

.

Am J Transplant

. 2009; 9: 258-268.

Slide18

CMV Diagnostics: PCR Standardization

Fryer et al. WHO ECBS Report. 2010.

Slide19

Hirsch et al. Clin Infect Dis. 2013;56:367–373

CMV Diagnostics:

PCR Standardization

Slide20

Do we know how to Prevent CMV Infection?

Universal vs. Pre-emptive therapy

Slide21

CMV Prophylaxis Strategies

Screening of blood and organ donors

Reduction of risk with leukocyte-filtered blood

Active immunization

Experimental and not currently utilized

Passive immunization

Non-selected polyclonal IgG

CMV

hyperimmune

polyclonal globulin

Monoclonal antibody to CMV

Antiviral Strategies

Universal Prophylaxis

Pre-emptive Therapy

Slide22

CMV Prophylaxis Strategies

Universal prophylaxis

Administration of antiviral agents to all individuals at risk for a fixed duration

May increase cost, toxicity, risk of resistance

Preemptive therapy

Administration of antiviral therapy in response to a positive microbiologic assay or clinical scenarios

Requires careful monitoring, close patient contact, and use of highly sensitive, quantitative assay

41% missed screening before onset

Hybrid Approach

Limited data to support the use of this approach

Slide23

CMV disease in D+/R- renal recipients: Meta-analysis (all agents)

Universal and Pre-emptive prophylaxis significantly reduce the risk of CMV disease

-81%

-64%

-100%

-80%

-60%

-40%

-20%

0%

Universal

Pre-emptive

CMV disease risk reduction (%)

p=ns

Kalil AC

et al. Ann Intern Med

2005; 143: 870

Slide24

Effect of anti-CMV prophylaxis on concomitant infections

Relative risk

-73%

-69%

-35%

Hodson

EM

et al. Lancet 2005; 365: 2105

Pneumocystis

Slide25

Statistically significant risk reduction of mortality with universal prophylaxis (Kalil et al) and all cause mortality (Hodson et al).

Mortality: universal prophylaxis vs. pre-emptive therapy

Mortality: risk reduction (%)

Kalil AC

et al. Ann Intern Med

2005; 143: 870Hodson EM et al. Lancet 2005; 365: 2105

p=0.032

Slide26

Anti-CMV Prophylaxis Is Associated With Increased Renal Graft Survival at 4 Years (P = 0.0425)

100

90

80

70

60

50

0

Oral ganciclovir prophylaxis

IV preemptive therapy

Freedom from graft loss;

uncensored for death (%)

1

2

3

4

Time after transplantation (years)

Kliem V, et al

. Am J Transplant

. 2008;8:975-983.

(B)

Khoury

JA, et al.

Am J Transplant

. 2006;6:2134-2143. (VGCV) (B)

Reischig

T, et al.

Am J Transplant

. 2008;8:69-77. (VACV) (B)

P

value (Log rank test) = 0.0425

Prophylaxis reduced CMV infection by 65% (

P

< 0.0001)

Slide27

Possible Immune Mechanisms: Infection and Allograft RejectionTrue but …?

Heterologous Cross-reactivity

Microbial-specific T cell

recognizes also

allo-MHC

DC maturation and

Inflammatory cytokine secretion

Cytokines

Microorganism

Riella LV. Kidney Transplant iBook 2015

Nonspecific upregulation of immune response

Specific Cross reactive immunity

Slide28

Circulating CMV-specific T cells also reacts to alloantigen

Heutinck et al. AJT 2016

CFSE

CMVA2/NLV

Donor stimulation

Third party stimulation

Slide29

Indirect Effects of CMV: Organ-specific

Renal: Decreased early graft function and some chronic dysfunction (increased by HHV6 and HHV7)

Acute but possibly not chronic allograft rejection is reduced by CMV prophylaxis

Liver: CMV associated with cirrhosis, graft failure, need for

retransplantation

& death

More aggressive HCV recurrence and fibrosis after

OLTx

(partially attributed to HHV6)

CMV disease is preventable

Heart: cardiac allograft vasculopathy

Reduced by

ganciclovir

+/- CMV

Ig

Lungs: CMV and D+/R- associated with Bronchiolitis Obliterans Syndrome, infection, death

Reduced by iv

ganciclovir

+/- CMV

Ig

Pancreas: Not studied (no CMV yet in islets)

Slide30

Chronic allograft dysfunction: How long to prophylax?

Chronic

allograft nephropathy (CAN)

Chronic allograft lung dysfunction (CLAD)

Chronic

allograft vasculopathy (CAV)

Vanishing

bile duct syndrome (VBDS)

CMV

BKV

CARV

HCV

Aspergillus, Pseudomonas

CMV

Slide31

Prophylaxis: 100 vs. 200 Days of Valganciclovir

Humar

et al. Am J Transplant. 2010; 10: 1228-1237.

Study: CMV D+/R- Renal Transplant Recipients

36.8%

16.1%

P < 0.0001

No difference in rejection:

100

d

: 17% vs. 200

d

: 11%

More

leukopenia

:

100

d

: 4% vs. 200

d

: 19%

Slide32

Prolonged Prophylaxis: Lung Transplantation

Finlen

Copeland

et al

.

J Heart Lung Transplant

. 2011;30:990-996.

Slide33

Delayed-Onset CMV

Arthurs

et al

. Clin Infect Dis. 2008; 46: 840-846.

Slide34

Current Recommendations for Duration of Prophylaxis

Slide35

Available Antiviral Agents: Mechanisms

Lurain NS, Chou SW. Clin Micro Rev. 2010; 23: 689-712.

Slide36

CMV-specific Cellular Immune Assays: Can we stop prophylaxis?

AssayAdvantagesLimitationsIntracellular Cytokine Staining (ICS)Identification of CD4+ and CD8+ T cellsQuantitative and qualitativeWhole blood assay or PBMCFlow cytometer assayNot standardized QuantiFERON-CMVWhole blood assay; Simple to performCD8+ responses only. Sensitive to lymphopenia. Some HLA types not covered in assayELISPOTIdentifies both CD4+/CD8+ T cells Purified PBMC Not standardizedMHC multimer stainingRapid, Whole blood or PBMC  CD8+ responses onlyFlow cytometerHLA and epitope specificNot standardizedNot Functional AssayImmunKnowCD4+ responsesiATP levels Not specific for CMV

Slide37

Can CMV-specific Immune Monitoring be used to determine duration of prophylaxis?

Figure 1. Distribution of CMV-specific CD4 T-cell frequencies among individuals that were CMV-seropositive (n=294; white circles) and CMV seronegative (n=94; black circles), respectively

. CMV-specific T cells were flow cytometrically quantified for production of interferon-γ after stimulation with CMV antigen (median 2.03%; black bar). The lower limit of detection is 0.05%. There was no difference in T-cell frequencies among the subgroups of control persons, patients with chronic renal failure, and renal transplant recipients (P =0.72; Kruskal-Wallis test; data not shown).

Copyright © 2016 Transplantation. Published by Lippincott Williams & Wilkins.

37

Sester, Martina et al. Transplantation. 76(8):1229-1231, October 27, 2003.

Slide38

CMV Cellular Immunity: Assays remain suboptimal but may be useful for risk at end of prophylaxisOptimal Assay may study both CD4 and CD8+ cells?

Agreement of intracellular cytokine staining + FACS with CMV serology is good; 12.5% of FACS= indeterminate. Agreement of ELISPOT or the ELISA-based Quantiferon assay with serology is moderate  assay optimization with CMV lysate and CMV particle compared to pp65 peptide pool antigen (CD4 T cells). ELISA  large number of samples indeterminate. In CMV-seropositive individuals, ELISPOT and Quantiferon-CMV assays provided 46% concordance with the serology, 12% discordance, 18% disagreement between ELISPOT or Quantiferon-CMV and the serology, and 24% gray areas when one or both tests resulted in weak positives. CD4+ T-cells pp65-specific useful to identify R(+) patients at increased risk of CMV replication. CD8+ cell-mediated immunity (interferon-based assay) to predict late onset cytomegalovirus disease in high risk SOT. Reconstitution of T-cell response correlates with control of CMV

T. Schmidt et al, American Journal of Transplantation 2014; 14: 2159–2167; Walker S, et al.

Transpl

Infect Dis 2007; 9: 165–170;

Giulieri

S, Expert Rev Mol

Diagn

2011; 11: 17–25. A.

Egli

et al.

Journal of Translational Medicine

2008, 6:29; D. Abate et al. Journal of

Virological

Methods 196 (2014) 157– 162; Kumar D et al. Am J Transplant 2009; 9(5): 1214–1222; Manuel O et al.

Clin

Infect Dis 2013; 56(6): 817–824; D. Abate et al. J

Clin

Microbiol

51 (8): 2501-7; G.

Gerna

Am J Transplant 2006; 6: 2356-64.

Slide39

Therapeutic Options

Slide40

With Clinical CMV Resistance

UL97 kinase – increase

GCV

(6.5-10mg/kg/day) or

foscarnet

(watch Mg+, seizures, iv only)

UL54 polymerase –usually include resistance to other drugs



foscarnet

or

cidofovir (iv only, renal toxicity)

Pan-resistance – new drugs?

+ CMV Immune globulin?

+ Leflunomide (LFTs, Levels)

Combination (GCV/

Fos

)

Atesunate

?

Slide41

Current Therapeutic Advantages and Limitations: Foscarnet

AdvantagesExperience (more limited)EfficacyNo drug interactionsCovers CMV, HSV, varicella, other herpes viruses

Limitations

Nephrotoxic

Electrolyte disturbances

IV only, often in hospital

Cost (including hospitalization)

Need for renal dosing

Treats active disease/doesn’t eliminate risk of subsequent disease (after end of treatment)

Slide42

Available Antiviral Agents: Mechanisms

Lurain NS, Chou SW. Clin Micro Rev. 2010; 23: 689-712.

Slide43

Avery RK, et al.

Transplantation

. 2016;100(10):e74-e80.

Slide44

Use of Cidofovir for Cytomegalovirus Disease Refractory to Ganciclovir in Solid Organ Recipients

Bonatti H, et al.

Surg

Infect

(Larchmont). 2017;18(2):128-136.

Slide45

CMV Resistance UL97 Targets

Slide46

Antiviral resistance – Polymerase targets

From Chou et al in CMV Guidelines, Transplantation 2018, in press.

Slide47

Verkaik

et al Transplant ID 2013, 15, E243. Leflunomide

Slide48

CMV Newer Options – the basics

Maribavir

(UL97 – viral maturation and egress) –

failed prophylaxis study in SOT

(wrong dose?)

Does not cover HSV/VZV

Mixed results in therapy

Failed in liver SOT and HSCT Prophylaxis

(but low dose)

Effective in small trials at higher doses but relapse occurred ~37%

Unique resistance mutations in UL97 (not cross reactive with GCV)

Letermovir

(viral

terminase

) UL56, oral and intravenous (studied in HSCT)

Prophylaxis only trials

Does not cover HSV/VZV

Easy resistance in vitro /

Drug interactions

with

CyA

, tacrolimus, voriconazole, others

Activity for treatment is unknown.

CMX001 (

Brincidofovir

) lipid cidofovir prodrug (oral only), covers herpesviruses

GI toxicity

Iv under development

Expected UL54 mutations (like cidofovir)

Slide49

Maribavir

UL97 kinase inhibitorElicits a different set of UL97 mutations, clustered around ATP binding siteOverlap with ganciclovir-resistant mutationsCovers CMV, EBV (need acyclovir for HSV/VZV prevention)May have less impact on lymphoproliferative/CMV-specific cellular immune responses than ganciclovir

ATP, adenosine triphosphate.

Stachel

D, et al.

J Clin

Virol

. 2016;75:53-59.

Slide50

D+R- liver transplant

Phase 3

?Dosing issue

Maribavir

Ganciclovir

CMV disease12%8%CMV disease or infectionat 100 d60%20%CMV disease or infectionat 6 mo72%53%

Winston DJ, et al.

Am J Transplant

. 2012;12(11):3021-3030

.

Slide51

Maribavir for Treatment of Cytomegalovirus Infections Resistant or Refractory to Ganciclovir or Foscarnet in Solid Organ Transplant Recipients: A Phase 2 Study

PCR, polymerase chain reaction

MBV 400 mg BID

Wks 1–3

Wks 3–6

Wks 6–24

MBV 1200 mg BID

• MBV doses blinded

Randomization

• HCT or SOT recipient

• R/R CMV

• ≥1000 CMV DNA copies/mL

At Week 3 and Week 6 visits, minimum virologic responses are required for study drug treatment to continue

PCR CMV testing

Day 1, weekly to Week 6

Study evaluations/PCR CMV testingEvery 2 weeks to Week 12; Weeks 16, 20, and 24

Week 4

Week 8

Week 12

MBV 800 mg BID

Screening

Study drug administration

(maximum 24 weeks)

Follow-up

(post-treatment Weeks 1–12)

Week 1

Slide courtesy of M. Pereira, presented at

The Joint Annual Congress of the American Society of Transplant Surgeons and

The American Society of Transplantation

Wednesday May 3, 2017

ClinicalTrials.gov

Identifier: NCT01611974

Slide52

Maribavir R/R Phase II Trial: Primary Efficacy Endpoint: Undetectable CMV Viral Load Within 6 Weeks (ITT-S Population)

Viremia clearance was similar between dose groups

Error bars indicate 95% CIsCI=confidence interval

70.0

62.5

67.5

66.7

MBV

400 mg BID(n=40)

MBV 800 mg BID(n=40)

MBV 1200 mg BID(n=40)

MBV All doses(N=120)

Slide courtesy of M. Pereira, presented at

The Joint Annual Congress of the American Society of Transplant Surgeons and

The American Society of Transplantation

Wednesday May 3, 2017

ClinicalTrials.gov

Identifier: NCT01611974

Slide53

Maribavir R/R Phase II Trial: Time to Undetectable Plasma CMV DNA

Median estimated time to confirmed undetectable plasma CMV DNA at any time (days [95% CI]) were similar: 24 (15, 31), 28 (15, 38), 22 (19, 30), and 23 (21, 29) for MBV 400 mg, 800 mg, 1200 mg (BID), and MBV all doses, respectively

0

7

14

21

28

42

49

56

63

70

77

84

91

98

105

112

119

126

133

140

147

154

161

168

175

182

189

196

203

210

217

224

231

238

35

MBV 400 mg BID

MBV 800 mg BIDMBV 1200 mg BIDMBV All doses

Treatment (days)

Undetectable CMV viral load (%)

1.00

0.80

0.70

0.60

0.50

0.40

0.30

0.20

0.10

0.00

0.90

All doses

Slide courtesy of M. Pereira, presented at

The Joint Annual Congress of the American Society of Transplant Surgeons and

The American Society of Transplantation

Wednesday May 3, 2017

ClinicalTrials.gov

Identifier: NCT01611974

Slide54

Maribavir R/R Phase II Trial: CMV Recurrence

No dose-dependent differences were noted in CMV recurrence rates

CMV recurrenceMBV 400 mg BID (n=40)MBV 800 mg BID (n=40)MBV 1200 mg BID (n=40)All doses(n=120)Patients achieving confirmed undetectable CMV DNA, n29273086Patients with CMV recurrence at any time during study treatment, n (%)*7 (24.1)11 (40.7)12 (40.0)30 (34.9)Treatment effect estimate by group, rate (95% CI)0.24 (0.10, 0.44)0.41 (0.22, 0.61)0.40 (0.23, 0.59)0.35 (0.25, 0.46)Patients with CMV recurrence post-study drug (off-treatment),† n (%)1 (3.4)2 (7.4)2 (6.7)5 (5.8)

*Denominator is the number of patients achieving confirmed undetectable CMV DNA †Follow-up assessments through 12 weeks post-treatment

Slide courtesy of M. Pereira, presented at

The Joint Annual Congress of the American Society of Transplant Surgeons and The American Society of Transplantation Wednesday May 3, 2017 ClinicalTrials.gov Identifier: NCT01611974

Slide55

Chou et al, 2017.

Slide56

Maribavir: Emerging Data and Trials Underway

Phase 3, efficacy and safety of maribavir in transplant recipients with cytomegalovirus (CMV) infections that are refractory or resistant to treatment (ClinicalTrials.gov NCT02931539)Study for the treatment of cytomegalovirus (CMV) infection in hematopoietic stem cell transplant recipients (ClinicalTrials.gov NCT02927067)

brincidofovir &

letermovir

not currently available via compassionate use

Slide57

Letermovir

Terminase

complex inhibitorBinds at UL56Generally good safety profile (low rate of side effects) Drug interactions with CyA, tacrolimus, voriconazole, othersCovers CMV only Need acyclovir for HSV/VZV preventionHigh-grade resistance mutations in UL56 terminase gene are readily selected in vitro with letermovir; clinical correlation needed (not UL97/UL54) (Chou 2015)

Griffiths PD, et al. N Engl J Med. 2014;370(19):1844-1846;RF Chemaly et al, N Engl J Med 2014; 370:1781-1789.

CyA

, cyclosporine A; VZV, varicella zoster virus.

Slide58

Letermovir

for Cytomegalovirus Prophylaxis in Hematopoietic-cell Transplantation

Phase 2 trial in HSCT

By 14 weeks, 6% letermovir vs. 42% placebo started CMV treatment By 24 weeks, 18% letermovir vs. 42% placebo had clinically significant CMVAll-cause mortality at week 24, 10% letermovir vs. 16% placeboThe highest dose (240 mg per day) had statistically significant protection early (before day 8).Few side effects

Chemaly RF, et al.

N Engl J Med

. 2014;370(19):1781-1789.;

Marty FM, et al. Presented at: Blood and Marrow Transplantation (BMT) Tandem Meetings; February 23-26, 2017; Orlando, FL

Slide59

Letermovir

Allogenic HSCT study Recipient CMV seropositivePlacebo controlled (letermovir: placebo, 2:1) × 14 weeks(≈100 days)Preemptive therapyNo valganciclovir—bone marrow suppressionBy 14 weeks, 6% letermovir versus 42% placebo started CMV treatmentBy 24 weeks, 18% letermovir versus 42% placebo had “clinically significant CMV”All-cause mortality at week 24, 10% letermovir versus 16% placebo

Marty FM, et al. Presented at: Blood and Marrow Transplantation (BMT) Tandem Meetings; February 23-26, 2017; Orlando, FL

Slide60

Marty FM, et al. Presented at: Blood and Marrow Transplantation (BMT) Tandem Meetings; February 23-26, 2017; Orlando, FL.

Slide61

Slide62

Novel Anti-CMV Agents: Letermovir

Marty et al. N Engl J Med. 2017;377:2433-2444.

Slide63

Brincidofovir

Lipid conjugate of cidofovirIn vitro antiviral activity against all 5 families of dsDNA viruses that cause human disease: HerpesvirusesAdenoviruses Polyomaviruses(eg,BK virus) PapillomavirusesOrthopoxviruses

Registration Announcement:

Chimerix

, Inc.

https://www.sec.gov/Archives/edgar/data/1117480/000114420413054339/v356753_s1.htm

Slide64

Patients received the study drug after engraftment for 9 to 11 weeks, until week 13 after transplantation

Incidence of CMV events was significantly lower among patients who received CMX001 compared with placebo (10% vs 37%)

Diarrhea was dose limiting, at 200 mg twice weekly

Myelosuppression and nephrotoxicity not observed

Slide65

Brincidofovir: Phase 3 SUPPRESS Trial (HSCT)

Compared brincidofovir prophylaxis versus placebo for first 14 weeks (100 days) post-HSCT, then followed for 10 weeksAdult CMV-seropositive HSCT recipients randomized 2:1 to brincidofovir 100 mg biweekly or placebo, n = 452By week 14, antiviral effect seen at end of treatment Brincidofovir arm had fewer clinically significant CMV infections compared with placebo group (24% vs 38%, P =.002)By week 24, brincidofovir (51%) clinically significant CMV infections, similar to placebo (52%) Brincidofovir arm: more diarrhea, more empiric treatment of GVHD (corticosteroids and other immunosuppressive therapies)8× increased use of corticosteroids through week 14 in the brincidofovir arm compared with placebo arm (median cumulative prednisone equivalent 26 mg/kg vs 3 mg/kg)Higher CMV infections in brincidofovir arm b/w weeks 14 and 24 (22% vs 11%) when off drugCompany evaluating intravenous versus other delivery

Marty FM, et al. Biol Blood Marrow Transplant. 2016;22(3):S23.

GVHD, graft-versus-host disease;

HSCT, hematopoietic stem cell transplantation.

Slide66

Brincidofovir (CMX-0001)

Slide67

Slide68

1.

Chemaly

RF, Ullmann AJ,

Stoelben

S, et al.

Letermovir

for cytomegalovirus prophylaxis in hematopoietic-cell transplantation. N

Engl

J Med. 2014;370(19):1781-1789.

2.

Stoelben

S,

Arns

W, Renders L, et al. Preemptive treatment of Cytomegalovirus infection in kidney transplant recipients with

letermovir

: results of a Phase 2a study.

Transpl

Int. 2014;27(1):77-86.

3. Marty FM, Ljungman P, Papanicolaou GA, et al.

Maribavir

prophylaxis for prevention of cytomegalovirus disease in recipients of allogeneic stem-cell transplants: a phase 3, double-blind, placebo-controlled,

randomised

trial. Lancet Infect Dis. 2011;11(4):284-292.

4. Winston DJ, Young JA,

Pullarkat

V, et al.

Maribavir

prophylaxis for prevention of cytomegalovirus infection in allogeneic stem cell transplant recipients: a multicenter, randomized, double-blind, placebo-controlled, dose-ranging study. Blood. 2008;111(11):5403-5410.

Slide69

Vaccine CategoryAntigen UsedManufacturerPhaseDNA (plasmid)pp65, gBAstellas Pharma US, Inc., Vical1, 2, and 3Vectoredpp65, gB, UL123/IE1-exon 4, UL122/IE2-exon 5AlphaVAx, Inc (Novartis, GSK)City of Hope, Hookipa Biotech, National Heart, Lung, and Blood Institute(NHLBI), NCI1, 2Attenuated and DISCgB, pp65, IE1CMV Research Foundation, MerckUniversity of California at San Francisco, Vical1Recombinant/SubunitgBGSK, National Institute of Allergy and Infectious Diseases(NIAID), University College London1, 2Recombinant/VLP gBCanadian Center for Vaccinology and VBI Vaccines, Inc.1Peptidepp65, T cell fused to tetanus epitope or PADRECity of Hope, NCI1, 2

Schleiss MR. J Virus Erad. 2016;2(4):198-207.

DISC,disabled single-cycle; VLP,virus-like particle.

Cytomegalovirus Vaccines

Under Clinical Development

Slide70

Antigen

Glycoprotein E (gE) -

50 µg

Adjuvant System

AS01

B

(

MPL and QS-21*) - 50 µg each

VaccineNon-live

gE

DNA

Nucleocapsid

Lipid envelope

Glycoprotein spikes

Tegument

MPL

Samonella minnesota

R595 strain

Phospholipid bilayer

Aqueous core

MPL

Liposome

Saponin QS-21

*

Vaccine Composition: Zoster Subunit Vaccine

* QS-21 (Quillaja saponaria Molina, fraction 21; licensed by GSK from Antigenics LLC, a wholly owned subsidiary of Agenus Inc., a Delaware, USA corporation)

Slide71

ZOE-50 and ZOE-70

Reactogenicity Subgroups

1,2

Solicited Local Symptoms Reported During 7 Days Post-VaccinationAny Grade Overall By Subject

ZOE-50: Overall median duration of 3 days for pain, redness, and swelling

ZOE-70 : Overall median duration of 2 days for pain; 3 days for redness and swelling

Lal H, Cunningham A, Godeaux O, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. NEJM 2015;372:2087-96.Cunningham AL, Lal H, Kovac M, et al. Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age and Older. NEJM 2016;375:1019-32

Percentage (%)

N= Number of subjects with at least one documented dose

%= Percentage of subjects reporting the symptom at least once when the intensity is maximum

Slide72

Q3 (75

th percentileMedian (50th percentile)Q1 (25th percentile)

Plot of frequency of gE-specific CD4(2+) T-cell/10E6 quartiles at Month 0, 3, 12, 24, 36, 48, 60, 72 and 108 in subjects vaccinated with HZ/su (ATP cohort for immunogenicity Y9)

Fold increase over pre-vaccination

Sustained

Cellular Immune

Response

(

Overall

)

Slide73

Slide74

Autologous T-cell therapies

Helen E. Heslop, and Ann M.

Leen

Hematology

2013;2013:342-347

Slide75

Autologous T-cell Therapy: 13 SOT recipients with recurrent or ganciclovir-resistant CMV infection were treated with in vitro–expanded autologous CMV-specific T cells.

CMV-specific T-cell therapy from peripheral blood mononuclear cells (PBMCs) stimulated with peptide pool including predefined HLA class I– and class II–restricted peptide epitopes from pp65, pp50, IE-1, gH, and gB. Cells were predominantly CD3+CD8+ T cells. Eleven (84%) patients failing antiviral therapies showed improvement in symptoms, including complete resolution or reduction in DNAemia and CMV-associated end-organ disease and/or the cessation or reduced use of antiviral drugs. Four patients showed coincident increased frequency of CMV-specific T cells in peripheral blood after completion of T-cell therapy.

C Smith et al. Autologous Adoptive T-cell Therapy for Recurrent or Drug-resistant Cytomegalovirus Complications in Solid Organ Transplant Recipients: A Single-arm Open-label Phase I Clinical Trial,

Clin Infect Dis

2019: 68 (4) 632–640,

https://doi.org/10.1093/cid/ciy549

.

Slide76

Helen E. Heslop, and Ann M.

Leen Hematology 2013;2013:342-347

Slide77

CMV “Immune Effects”: Possible Mechanisms

Upregulation

of MHC class II antigens and homolog of MHC class-I

(HLA-DR

,

Fujinami

RS, et al.

J

Virol

.

1988;62:100-105. S. Beck,

Nature.

1988;331:269-272)

Blocks CD8+ (MHC class I) recognition

Blocks CMV antigen processing and display (immediate early Ag modification, poor CTL response)

Increased ICAM-1, VCAM, cellular

myc

&

fos

Inversion of CD4/CD8 ratio

(Schooley 1983, Fishman 1984)

Increased cytokines: IL-1

, TNF, IFN, IL-10, IL-4, IL-8, IL-2/IL-2R,

C-X-C

chemokines

and IL-8

(Kern et al, 1996; CY Tong, 2001)

Increased

cytotoxic

IgM

(Baldwin et al, 1983)

Stimulation of alloimmune response by viral proteins

(

Fujinami

et al, 1988, Beck et al, 1988)

Increased PDGF, TGF



Increased

granzyme

B CD8+ T-cells,

-T-cells

Slide78

Opportunistic Infections Promoted by CMV Infection in Transplant Patients

Pneumocystis cariniiFungal infections (esp. intra-abdominal transplants): Candidemia and intra-abdominal infection in OLTx; patients with initial poor graft functionAspergillus spp. Role of CMV in promoting fulminant HCV hepatitis rather than direct effectBacteremia: Listeria monocytogenesEpstein-Barr virus infection (RC Walker et al, CID, 1995, 20:1346-55), HHV6, HHV8/KSHV? HCV: risk for cirrhosis, retransplantation, mortality

Slide79

Pig Ureter Pig Kidney Baboon LN

Mueller et al. PCMV in pig-to-primate xenotransplantation

PCMV

Slide80

A

Gollackner

et al.

B

PCMV induces endothelial cell activation

in vitro

with

procoagulant

expression

:

pTF

upregulation

in MV-infected PAEC. White bars show TF in control cells, shaded bars show

upregulation

in infected cells.

Immunohistochemistry

for porcine TF of a pig kidney of Group 1 excised on day 29 for CC (B69-169)

Slide81

GalT-KO thymokidney xenograft survival in baboons treated with ant-CD40L based regimens at MGH 2003–2012: Impact of PCMV infection. Bars indicate xenograft survival markedly decreased since mid-2008 associated with relocation of the breeding colony to a new facility in late 2007. Animals born in the new facility were used as donors of thymokidneys since mid 2008 (see Yamada K et al. Transplantation, 2014, ;98(4):411-8.)

PCMV Introduced

Slide82

Mechanisms?

Hand waving or Magic?

How does CMV predispose to graft rejection and opportunistic infection at the same time?

Slide83

CMV interfaces with innate and adaptive immune systems

Crough and Khanna,

Clin

Microbiol Rev 2009

Primary infection with HCMV  replication in mucosal epithelium HCMV  monocytic cells of myeloid lineage = “latent infection” with limited viral gene expression. Differentiation of virus-infected monocytes into macrophages  productive infection (stimulate T cells)Virus particles or virus-associated dense bodies  antigen-presenting cells (e.g., DCs)  stimulate antigen-specific T cells + cytokines & chemokines innate immunity (e.g., NK cells)Activated T cells (CD8+, CD4+, and/or γδ T cells) and NK cells lyse virus-infected cells B cells control extracellular virus through antibody-mediated neutralization.

CMV: Complex Interactions with Immune System

Slide84

HCMV Protein

Function

FC Receptor homologue

TRL11/IRL11, UL118/119

Blocks antibody-dependent cytotoxicity; binding nonspecific antibody coating against CD8 and NK cells

Pp65 matrix

Phosphorylates IE-1 protein to inhibit MHC class I-restricted antigen presentation

US3,US6, US10, US11

Block generation and export of MHC class I peptides

US3,US6, US10, US11

Reduced expression of MHC class I peptides

US2

Reduced antigen presentation in MHC class II pathway

MHC-I homologue UL40, UL122 miRNA, UL142, UL141

Blocks NK cell activation (also: UL16, pp65)

UL18

MHC class 1 homologue; reduced immune surveillance

UL20

T-cell receptor homologue; reduced antigen presentation

IE86

Inactivates p53; increase smooth muscle proliferation

UL33, UL33, UL78, US27, US28

Transmembrane proteins chemokine receptors; reduced interferon and chemokine effects; reduced inflammation, increased viral dissemination

IL-10 homologue UL111a;

IL8 CXC-1 UL146, UL147

Immunosuppression; reduced MHC class I/II expression and lymphocyte proliferation; increased neutrophil chemotaxis; reduced dendritic cell and monocyte chemotaxis and function

UL144

TNF receptor homologue

UL36, UL37

Anti-apoptosis for infected cells

Slide85

CMV Infection and “Parasitism”: Many Mechanisms are CMV-specific

Upregulation of MHC class II antigens and homology between CMV IE antigen and MHC class-I

(HLA-DR

,

Fujinami RS, et al.

J

Virol

.

1988;62:100-105. S. Beck,

Nature.

1988;331:269-272)

Block of CD8+ (MHC class I) recognition of CMV

Blocks CMV antigen processing and display (immediate early Ag modification, poor

allo

-T-cell CTL response)

Increased ICAM-1, VCAM, cellular

myc

&

fos

(adhesion)

Inversion of CD4/CD8 ratio

(Schooley 1983, Fishman 1984)

Increased cytokines: IL-1

, TNF, IFN, IL-10, IL-4, IL-8, IL-2/IL-2R,

C-X-C chemokines and IL-8

(Kern et al, 1996; CY Tong, 2001)

Increased cytotoxic IgM

(Baldwin et al, 1983)

Stimulation of alloimmune response by viral proteins

(Fujinami et al, 1988, Beck et al, 1988)

Increased PDGF, TGF

; autoantibodies

Increased granzyme B CD8+ T-cells,

-T-cells

Slide86

Mechanisms: CMV with Monocytes and Dendritic Cells

In vitro, CMV infection of human monocytes results in a

transient block in the cytokine-induced differentiation of monocytes into functionally active CD1a-positive dendritic cells

. Dendritic cells are important

antigen presenting cells

and play a central role in generation and maintenance of primary T-cell responses against viral infections. HCMV-infected CD1a-negative cells are unable to induce a T-cell response.

Depressed immunological functions include:

Impaired ability to mature in response to LPS.

Reduced phagocytic capacity

Reduced migration

in response to chemoattractant factors RANTES, MIP-1, and MIP-3 (reduced the cell-surface expression of CC chemokine receptor 1 (CCR1) and CCR5 by receptor internalization).

CMV infection induces

secretion of inflammatory chemokines

, chemokine ligand 3 (CCL3), macrophage inflammatory protein-1 (MIP-1), CCL4/MIP-1ß, and CCL5/regulated on activation, normal T expressed and secreted (RANTES)

 inflammatory milieu

HCMV-infected cells express high levels of the costimulatory molecule CD86

S.

Gredmark

and C.

Söderberg-Nauclér

*Journal of Virology, October 2003, p. 10943-10956, Vol. 77, No. 20

Slide87

Unbiased Transcriptome Profiling: RNASeq and Workflow

Slide88

Volcano plots of genes: log fold change in CMV-infected THP-1 (monocyte) cells

Similar changes seen in primary human monocytes infected in vitro with HCMV.

Significance of Changes

Fold Changes in Gene Expression

Sen,

ElKhoury

, Fishman – unpublished data

Slide89

Pathways altered by CMV

Slide90

Transcriptomic profiling of CMV-infected THP-1

mock

IFN

γ

IL-4/IL-13

IL-6

IL-10

TGF

β

CMV

Log 2 fold change

Count

Slide91

Unbiased transcriptomic profiling of CMV-infected THP-1 using RNASeq

Phagocytosis

Antifungal

Inflammasome

Antiviral

Antibacterial

CMV

mock

mock

IFN

γ

IL-4/IL-13

IL-6

IL-10

TGF

β

CMV

Log 2 fold change

Count

Sen,

ElKhoury

, Fishman – unpublished data

Slide92

Slide93

Slide94

CMV: In vitro infection of monocytes

Sen et al, submitted

Slide95

If I can help:

jfishman@mgh.harvard.edu

Thank you!!