Low incidence of adenovirus hemorrhagic cystitis following autologous hematopoietic stem cell transplantation in the rituximab era
Authors: Yasuo Mori, Toshihiro Miyamoto, Kenjiro Kamezaki, Koji Kato, Yoshikane Kikushige, Shuichiro Takashima, Shingo Urata, Shinji Shimoda, Nobuyuki Shimono, Katsuto Takenaka, Hiromi Iwasaki, Koji Nagafuji, Takanori Teshima, Koichi Akashi
Journal: American Journal of Hematology (2012)

Viral hemorrhagic cystitis (HC) is a frequent complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT) but is rare after autologous peripheral blood stem cell transplantation (auto-PBSCT) because immunosuppression is not required in the absence of an allogeneic immune reaction. Recently, auto-PBSCT has been combined with novel anticancer agents targeting specific molecules, such as rituximab; however, these may cause severe immune deficiency and increase the susceptibility of transplant recipients to opportunistic infections. To address this issue, we performed a retrospective analysis of the incidence of viral HC in auto-PBSCT recipients. Of 158 recipients, only 4 cases (2.5%) were diagnosed with viral HC due to adenovirus (ADV), which was significantly less frequent compared with the incidence in allo-HSCT recipients (15.8%). The incidence of HC did not increase with rituximab treatment. This was a single-center retrospective analysis with a small sample size; however, incorporation of rituximab into the treatment of auto-PBSCT recipients did not appear to be a risk factor for developing viral HC. Viral HC is a noteworthy complication after HSCT because of its negative effects on the quality of life and its potential to cause therapy-related mortality [1]. We recently reported different risk factors associated with two viral HCs in allo-HSCT recipients [2]: ADV-HC and BKV-HC. ADV-HC is associated with severe immunodeficiency caused by immunosuppression therapies such as T-cell purging, whereas BKV-HC is associated with allogeneic immune hyperactivity such as graft-versus-host disease (GVHD) or the pre-engraftment immune reaction (PIR) [3]. Auto-PBSCT is characterized by rapid hematologic and immune reconstitution and does not trigger an allogeneic immune reaction that would require immunosuppressive therapy either for prophylaxis or for treatment. Consequently, there is lower incidence and severity of opportunistic infection including viral HC in auto-PBSCT recipients [4, 5]. The survival of auto-PBSCT recipients has significantly improved over the recent years because of the incorporation of novel anticancer agents targeting specific molecules into the treatment regimen [6]. One such anticancer agent widely used in this context is rituximab, a chimeric monoclonal anti-CD20 antibody that causes B-lymphocyte depletion. When used alone in patients with lymphoma, rituximab has few effects on the incidence of infectious complications [7, 8]. However, the combination of rituximab and high-dose chemotherapy (HDC) may increase the risk of viral infections [9-11], including that caused by the hepatitis-B virus (HBV) [12]. This retrospective study was conducted to clarify the prevalence, clinical features, and risk factors of viral HC after auto-PBSCT and to compare these variables with those of allo-HSCT. A total of 158 patients with hematological disorders or solid tumors hospitalized at our institute from 2000 to 2010 were enrolled. The clinical characteristics of these patients are summarized in Table I. A total of 101 patients had malignant lymphoma (ML), and the remaining 57 patients were diagnosed with acute myelogenous leukemia (AML; n = 13), plasma-cell disorders (e.g., multiple myeloma or primary amyloidosis; n = 36), or solid tumors (n = 8). Patients with one of the following conditions were classified as “chemotherapy-sensitive” (n = 132): ML and plasma cell disorders in at least partial remission and AML in first complete remission. All other patients (n = 26) were categorized as “chemotherapy-resistant.” A total of 101 ML patients were treated with the CHOP regimen [13] as induction therapy, HDC as a preparative conditioning regimen, followed by transplantation of unpurged autologous PBSCs. After approval of rituximab for the treatment of ML in Japan, 41 patients with CD20-positive lymphomas was treated with CHOP and auto-PBSCT combined with rituximab. Of these, 35 patients received rituximab in combination with the ranimustine, carboplatin, etoposide, and cyclophosphamide (MCEC) pretransplant regimen [14]. Four patients received rituximab combined with the melphalan, etoposide, cyclophosphamide, and dexamethasone (LEED) regimen [15] and 2 patients received rituximab in combination with other regimens. The remaining 60 ML patients were either treated before approval of the use of rituximab or had CD20-negative lymphoma and received HDC consisting of MCEC (n = 52), LEED (n = 2), or another regimen (n = 6), all without rituximab. Plasma cell disorders (n = 36) were treated with the VAD regimen [16] or bortezomib-based induction therapy followed by high-dose melphalan before auto-PBSCT [17]. Standard-risk AML patients (n = 13) achieved complete remission after conventional remission induction and consolidation chemotherapy and received the busulfan, cytarabine, and etoposide (BEA) conditioning regimen followed by auto-PBSCT [18]. Eight patients with solid tumors underwent standard chemotherapies based on each diagnosis and then received auto-PBSCT. Of these, five patients received the high-dose ICE regimen [19]. Acyclovir prophylaxis was used to protect against reactivation of herpes simplex virus (HSV) in all these recipients. Urinalysis was routinely performed at least once a week from the initiation of preparative regimens until discharge from hospital or when clinical signs of cystitis appeared after the discharge. Microscopic or macroscopic hematuria and/or bladder irritation was further analyzed using polymerase chain reaction (PCR) to detect viral DNA (ADV, BKV, and JC virus). Methods for detecting each type of viral DNA have been reported previously [20-22]. In brief, after 2 ml of a urine sample was centrifuged (15,000g for 1 hr), DNA was purified from the sediment using the QIAmp DNA Blood Mini Kit (Qiagen, Hilden, Germany). Next, 5 ml of purified DNA was subjected to PCR using the GeneAmp Kit and GeneAmp PCR System 9600 (PerkinElmer, Boston, MA) with the following primers: AD185S (5′-tccagcaacttcatgtccatgg-3′) and AD 185A (5′-tcgatgacgccgcggt-3′) for detecting ADV; BKV-1 (5′-gcaagtgccaaaactactaat-3′) and BKV-2 (5′-tgcatgaaggttaagcatgc-3′) for detecting BKV; and JTP-1 (5′-gcagcttagtgattttctcagg-3′) and JTP-2 (5′-ggacacaagaaaacaaaaccac-3′) for detecting JCV. The size of the final products was confirmed by agarose gel electrophoresis. Confirmation of viral HC by PCR was required for inclusion in our study. Four (one myeloma and three ML patients) of 158 auto-PBSCT recipients developed HC due to ADV. The incidence (2.5%) was significantly lower than that previously described by us in allo-HSCT recipients (42 of 266 allo-HSCT recipients (15.8%); 26 due to ADV and 16 due to BKV) but was consistent with that reported by other studies [23-26]. Three of 101 (3%) recipients with ML developed ADV-HC, which was similar to 1 of 57 (1.8%) patients suffering from other disorders (P = 0.64). There was no correlation between the incidence of ADV-HC and age, sex, disease status at transplantation, number of chemotherapies before auto-PBSCT, and the results of pretransplant titer of anti-ADV IgG antibody (Table I). Leung et al. proposed a three-step model for the pathogenesis of viral HC after allo-HSCT: (i) chemoradiation-induced damage to the uroepithelium provides a permissive environment for viral replication; (ii) viral reactivation occurs because of immunosuppression; and (iii) immunocompetent donor cells mount an immunological reaction against viral antigens expressed on the uroepithelium. This alloimmune attack perpetuates the mucosal damage and hemorrhage that characterizes HC, resulting in a higher incidence of HC induced by allo-HSCT rather than auto-HSCT [23-26]. In this study, ADV caused HC in four auto-PBSCT recipients, whereas BKV-HC or JCV-HC was not documented. One possible reason is that ADV is the prominent pathogen for HC in Japan [21, 23], whereas BKV is observed more frequently worldwide [24, 25]. This geographic prevalence may account for the greater incidence of ADV-HC described in our study [2] in comparison with similar studies from other countries. Alternatively, the difference may be due to inherent differences in ADV-HC and BKV-HC. Our previous study of allo-HSCT recipients revealed that BKV-HC occurred more frequently in patients with excessive allogeneic immune reactions such as GVHD and PIR, as hypothesized by Leung et al., whereas ADV-HC was closely associated with T-cell purging or underlying diseases, suggesting that severe immune suppression played a pivotal role in ADV reactivation. Similarly, the intensified myeloablative preparative regimen before auto-HSCT may provide a permissive environment for ADV replication on the damaged uroepithelium, inducing the immune suppression favoring the development of ADV-HC. Conversely, auto-HSCT lacks an alloimmune reaction, which may augment the immunological reaction against BKV antigens expressed on the uroepithelium, thereby accounting for the extremely low incidence of BKV-HC in auto-HSCT recipients. The clinical features of the four patients who developed ADV-HC are shown in Table II. The median onset of symptoms was 46.5 days (17–309 days), which was similar to the result observed in allo-HSCT recipients (49.5 days) [2]. All four patients suffered from macrohematuria and two suffered from bladder irritation. One patient received low-dose cidofovir (CDV; 1 mg/kg/day three times a week) [21] that resulted in viral eradication and significant improvement in symptoms, whereas the remaining three patients recovered with supportive care alone, including hyperhydration and forced diuresis; no patient required continuous bladder irrigation. In our experience, clinical symptoms of ADV-HC in auto-PBSCT recipients are less severe than those in allo-HSCT recipients; among 26 patients developing ADV-HC after allo-HSCT, 22 (85%) and 5 (19%) patients required CDV administration or continuous bladder irrigation, respectively [2]. According to the grading of renal toxicity by the common terminology criteria for adverse events Version 4.0 (May 2009), all four auto-PBSCT recipients with ADV-HC suffered grade-2 renal toxicity; however, of the 26 allo-HSCT recipients with ADV-HC, 5 had grade 1, 6 had grade 2, and 15 had grade 3 renal toxicity. These findings suggest that immunosuppression results in ADV reactivation and aggravates the symptoms of HC. Rituximab induces rapid depletion of mature B-cells, which remain at low or undetectable levels for several months before recovering to normal levels [27]. In addition to its effects on B-cells, there is growing evidence that rituximab also influences T-cell immunity and predisposes to opportunistic infections, including an increased incidence of viral infections such as HBV and cytomegalovirus (CMV) [[9-12]. Based on this information, we hypothesized that incorporation of rituximab into the treatment regimen with auto-PBSCT may lead to impaired immunity and increased susceptibility to viral HC. However, only one of the ADV-HC patients had received rituximab during their treatment regimen, and this did not alter the incidence of ADV-HC [1 of 41 (2.4%) vs. 3 of 117 (2.6%); P = 0.97]. When we considered only the patients with B-cell lymphoma (n = 82), the use of rituximab did not alter the incidence of ADV-HC [2.4% (1 of 41) in the rituximab group versus 4.9% (2 of 41) in the nonrituximab group; P = 0.56]; however, our limited sample size was not sufficient to detect significant differences. We also found no change in the incidence of other viral infectious complications-reactivation of the varicella zoster virus, HSV, or CMV occurred with similar frequencies among the auto-PBSCT recipients with and without rituximab (data not shown). A high incidence of viral infections such as HC in patients with autoimmune diseases who received CD34-purified auto-PBSCT has been reported [28], possibly due to a prolonged low number of CD4+ T-cells [29]. Similarly, there is a close relationship between T-cell depletion and ADV-HC development in allo-HSCT recipient [2, 30]. Based on these observations, we postulate that severe immunosuppression, mainly due to impaired T-cell function rather than rituximab-induced B-cell depletion plays an important role in the development of ADV-HC. Conversely, the inhibitory effect of rituximab on T-cell function would be minor in auto-PBSCT recipients. In conclusion, we found that the use of rituximab in auto-PBSCT did not increase the risk of viral HC. Because of the limitations inherent in a single-center retrospective analysis with a small sample size, these findings should be validated in a larger group of auto-PBSCT recipients. Yasuo Mori* , Toshihiro Miyamoto*, Kenjiro Kamezaki*, Koji Kato*, Yoshikane Kikushige*, Shuichiro Takashima*, Shingo Urata*, Shinji Shimoda*, Nobuyuki Shimono*, Katsuto Takenaka*, Hiromi Iwasaki , Koji Nagafuji*, Takanori Teshima , Koichi Akashi* , * Department of Medicine and Biosystemic Science, School of Medical Sciences, Kyushu University, Fukuoka, Japan, Center for Cellular and Molecular Medicine, School of Medical Sciences, Kyushu University, Fukuoka, Japan.