Evaluation of CMV dna antigenemia during allogenic bonerelevant patients

EVALUATION OF CMV DNA ANTIGENEMIA DURING ALLOGENIC BONE RELEVANT PATIENTS Merve KESKİNKILIÇ, MD Dokuz Eylul University School of Medicine, Department of Internal Medicine Hematopoietic stem cell transplantation (HSCN) is the collection of stem cells from a person's or tissue-group-compatible individuals to restore the hematopoietic system to the recipient under appropriate conditions. According to the relationship between the HSCN patient and the donor and the relationship between the anatomical source of the stem cells, three groups are distinguished as autologous HSCN, syngeneic HSCN and allogeneic HSCN. Allogeneic HSCN is the post-regulatory transfer of stem cells to the HLA donor-recipient donor recipient. The risk of cytomegalovirus (CMV) reactivation after allergen HSCN (AHSCN) reaches 30-50 % and CMV infections after transplantation is the most important cause of viral morbidity and mortality. Screening tests such as viral culture and serological methods are used to detect CMV infection. The serological method is less sensitive to CMV 65 kDa phosphoprotein (pp65) antigenemia. The detection of CMV DNA by the polymerase chain reaction (PCR) method is a more sensitive test and the level can be calculated quantitatively. In this study, immunosuppressive therapy, neutropenia, lymphopenia, hemoglobin level, thrombocytopenia, mobilization and preparation regimen, c-reactive protein (CRP) level, graft versus host disease (GVHD), the presence of galactomannan (GM) in the recipient, the investigation of CMV immunity, age, sex with the recipient and donor, and comparison with other measurement method PCR. The study included 138 specimens from 39 patients who had AHSCN between June 2009 and October 2016. Demographic characteristics of patients, clinical status, time of engraftment, transplant preparation regimens, graft versus host disease (GVHD) development status, CMV infection status, CMV immunity of the donor and donor, GVHD degree at the time of CMV infection, immunosuppressive therapy, white blood cell, neutrophil and Lymphocyte values were analyzed retrospectively. Female/ male rate was 1.05/1 and the median age was 38 ± 11 (18-64). When the laboratory values of the patients were examined, the mean hemoglobin (hb) was 10g / dL (5,5-15g / dL), the white blood cell count was 5100 x103/µL (200x103 / µL - 30900 x 103 / µL), and the mean platelet count was 69 x 103( 4 x 103 / µL-373x103 / µL), neutrophil (neu) 3200 x 103 / µL (100 x 103 / µL – 4500 x 103/ µL), lymphocyte 1200 x 103/ µL (10 x 103 / µL – 1360 x 103 / µL). CMV IgG at the time of transplantation was positive in 68 %, negative in 23 %, could not be reached in 9 %. In 17 % of the rotors CMV Ig G was negative and 83 % was IgG positive. All patients received methotrexate-cyclosporine as GVHD prophylaxis and valaciclovir as antiviral prophylaxis. The mean CD34 + cell count was 5,9 x 10 6 / kg (2-12 x 10 6 / kg), and the mean time to neutrophil engraftment was 12 days and the mean platelets engraftment was 15.7 days. 23,2 % (n: 32) were found to have undergone CMV infection after transplantation. Of the 7 patients who developed CMV infection, 6 had GIS infection and 1 had CMV pneumonia. All of them were given antiviral ganciclovir treatment, but 3 patients were treated with valganciclovir. Seven patients were treated with antiviral treatment for active infection and preemptive therapy for other patients. In 1 patient, sidefovir was switched to ganciclovir resistance Skin GVHD was found to be 42,8 %, skin and gastric GVHD 19,5 %, skin and lung GVHD 10.2 %, skin and hepatic GVHD 7,2 %, and 20.3 % GVHD were not found to have GVHD when the detected GVHD cases of CMV infected patients were examined . Immunosuppressive therapy was 54,4 % for steroid + cyclosporine combination, 19,2 % for cyclosporine 10,3 % for steroid, 9,5 % for steroid-cyclosporine-MMF combination and 6,6 % for prednol- tacrolimus combination. One patient underwent photopheresis treatment and two patient had mesenchymal stem cell therapy. As a result of the median 30-month follow-up, 76,8% of our cases who had allogeneic transplantation died and 23,2 % were alive. 138 episodes with CMV antigenemia and CMV DNA concurrent positivity were examined. White blood cell count, neutrophil and lymphocyte levels were evaluated. There was no statistical significance between the post-engraftment lymphocyte and CMV DNA titer (p = 0,07). When the lymphocyte count was divided into two as <500 and> 500 over, the patients with lymphocytes <500 had a significantly higher CMV DNA positivity rate (p = 0,017). There was statistically significant difference between lymphocyte count and CMV antigenemia (p = 0,038). As lymphocytes increased, antigenemia was higher. White blood cell count and neutrophil value were correlated with CMV DNA (p = 0,003, p = 0,002). Neutrophil value <1000, 1000-2000, > 2000 was also correlated with CMV DNA, as the neutrophil value increased CMV DNA titer increased (p = 0,027). There was also a statistical relationship between neutrophil value and CMV antigen (p = 0,034). Again, when the neutrophil values were examined with <1000 and > 1000 as CMV antigenemia, it was observed that the statistical relation was significant (p = 0,005). CMV antigenemia positivity was high in patients with neutrophil values> 1000. There was a significant correlation between CMV antigenemia and CMV DNA values (p = 0,033). In 8 of the samples (5.8%) CMV pp65 antigenemia and CMV DNA were PCR negative; In 49 (35.5 %) both tests were positive. The number of CMV antigenemia negative / CMV positive samples was 81 (58.7 %), whereas the positive / CMV PCR negative sample was not available. The mean value of the CMV PCR of 49 samples, which were positive in both tests, was 57.887 copies / ml (70 - 1.213.633 copies / ml). A significant correlation was found between the two tests and the positive samples (p = 0,018). ROC analysis showed that 322 copies / ml of CMV viral load corresponds to ≥ 1 antigen-positive cell / 200 thousand leukocytes (Sensitivity 68.5 %; Specificity 31.5 %). As a result, there is a significant relationship between pp65 and PCR tests used in CMV detection. White blood cells and neutrophil values affect CMV antigenemia and DNA results. There is a significant relationship between neutrophil and platelet engraftment and CMV antigenemia, and CMV positivity rate is higher in patients with late engraftment and CMV is seen in these cases. KEY WORDS: Allogeneic Hematopoietic Stem Cell Transplantation, CMV Infection, CMV Antigenemia (pp65), CMV DNA PCR, Neutrophil Engraftment