AntiCMV molécules Monitoring in Real-life in Stem Cell Recipients (NAViRe)
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ClinicalTrials.gov Identifier: NCT04690933 |
Recruitment Status :
Recruiting
First Posted : December 31, 2020
Last Update Posted : December 31, 2020
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Cytomegalovirus (CMV) is a ubiquitous herpesvirus that represent a major cause of morbidity in haematopoietic stem cell transplants (HSCT) recipients, mostly through reactivation of the recipient's virus.
If left untreated, 40 to 80% of patients will develop CMV infection, leading to CMV disease in 30 to 35 % patients, and associated with considerable morbi-mortality. Interstitial pneumonia is the most severe and specific manifestation, although CMV replication by itself has also indirect effects such as triggering graft versus host disease and increasing immunosuppression. The current burden of CMV infection increases by 25 to 30% the cost of the graft in France. This also includes the burden for refractory - infections, that represent up to 13% of recipients with CMV infection, including 3% of cases with virological resistance in France (data from the Reference Center cohorts).
Ganciclovir, or valganciclovir preemptive treatment, guided by CMV viral load follow-up allowed significant reduction of CMV disease to 2-6% but did not prevent CMV indirect effects. In addition, hematotoxicity can compromise post-transplant haematological reconstitution, thus preventing its use as prophylaxis in France. Foscarnet, iv-administered and nephrotoxic, remains less used. There is thus a high expectation from less toxic molecules for prophylaxis The development letermovir recently available for prophylaxis of CMV infection in high risk patients will modify the patients care and follow-up. This new molecule targeting CMV terminases (developed by Merck) was recently marketed in France (Jan 2020). However, the analysis of the letermovir phase III study and further publications show that the risk of emergence of resistance is low, but may occur in case of breakthrough and thus post AMM monitoring is required.
A "real-life" evaluation of these new molecules in terms of efficacy, emergence of resistance, tolerance and morbimortality related to CMV infection, is useful, to propose recommendations on management strategies, in particular for the most at-risk patients i.e. CMV-seropositive recipients. To this purpose, the National Reference Center in collaboration with the French Society for marrow graft and cell therapy (SFGMTC) set up a cohort of surveillance of allografted patients, receiving, in prevention or treatment, old and new molecules.
Condition or disease | Intervention/treatment |
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Hematopoietic Stem Cell Transplantation Cytomegalovirus Infections Antivirals Antiviral Drug Resistance | Other: Real-life observatory of efficacy and resistance to anti CMV molecules in stem cell recipients |
Cytomegalovirus (CMV) is a ubiquitous herpesvirus that represent a major cause of morbidity in haematopoietic stem cell transplants (HSCT) recipients, mostly through reactivation of the recipient's virus.
If left untreated, 40 to 80% of patients will develop CMV infection, leading to CMV disease in 30 to 35 % patients, and associated with considerable morbi-mortality. Interstitial pneumonia is the most severe and specific manifestation, although CMV replication by itself has also indirect effects such as triggering graft versus host disease and increasing immunosuppression. The current burden of CMV infection increases by 25 to 30% the cost of the graft in France. This also includes the burden for refractory - infections, that represent up to 13% of recipients with CMV infection, including 3% of cases with virological resistance in France (data from the Reference Center cohorts).
Ganciclovir, or valganciclovir preemptive treatment, guided by CMV viral load follow-up allowed significant reduction of CMV disease to 2-6% but did not prevent CMV indirect effects. In addition, hematotoxicity can compromise post-transplant haematological reconstitution, thus preventing its use as prophylaxis in France. Foscarnet, iv-administered and nephrotoxic, remains less used. There is thus a high expectation from less toxic molecules for prophylaxis The development letermovir recently available for prophylaxis of CMV infection in high risk patients will modify the patients care and follow-up. This new molecule targeting CMV terminases (developed by Merck) was recently marketed in France (Jan 2020). However, the analysis of the letermovir phase III study and further publications show that the risk of emergence of resistance is low, but may occur in case of breakthrough and thus post AMM monitoring is required.
A "real-life" evaluation of these new molecules in terms of efficacy, emergence of resistance, tolerance and morbimortality related to CMV infection, is useful, to propose recommendations on management strategies, in particular for the most at-risk patients i.e. CMV-seropositive recipients. To this purpose, the National Reference Center in collaboration with the French Society for marrow graft and cell therapy (SFGMTC) set up a cohort of surveillance of allografted patients, receiving, in prevention or treatment, old and new molecules.
Study Type : | Observational |
Estimated Enrollment : | 400 participants |
Observational Model: | Cohort |
Time Perspective: | Prospective |
Official Title: | Real-life Observatory of Efficacy and Resistance to Anti CMV Molecules in Stem Cell Recipients |
Actual Study Start Date : | September 24, 2020 |
Estimated Primary Completion Date : | September 24, 2022 |
Estimated Study Completion Date : | December 31, 2024 |
Group/Cohort | Intervention/treatment |
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Multicentric NAViRe cohort with biocollection
The National Reference Center (CNR) for cytomegalovirus with the French Society for Medullary Transplantation and Cell Therapy (SFGM-TC) has set up a surveillance cohort of allografted patients (NAViRe cohort) receiving, as prevention or treatment, Anti-Cytomegalovirus (Anti-CMV) molecules, "new or less recent", thus allowing the development of a new observatory evaluating in real life the potentials of these drugs in terms of efficacy, emergence of resistance, tolerance and morbidity and mortality associated with CMV infection.This work is useful to propose recommendations on management strategies, in particular for the most at-risk patients i.e. CMV-seropositive recipients and allows the emergence of an real-life observatory of efficacy and resistance to anti CMV molecules in stem cell recipients.
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Other: Real-life observatory of efficacy and resistance to anti CMV molecules in stem cell recipients
Signing of consent at the time of the pre-transplant consultation (1 month before grafting). Inclusion of patients during conditioning (around D-8 of transplantation). Samples related to the cohort:one blood sample from the donor (only familial donors) for genetic SNPs analysis. 5 samples: D-8, D20, D100, D200 (+/-10 days), 1 year : 1 tube of 7ml of whole blood on EDTA: Biobanking of whole blood for genetic SNPs analysis (D-8) of specific transporters for GCV, and of plasma for TTV viral load at all times. In routine care:samples taken in the event of a therapeutic escape (2 x 7 ml EDTA tubes, for resistance genotype, and ganciclovir dosage, 3 x 1 ml for Quantiferon CMV, according to CNR Herpesvirus recommendations. 1 x Paxgene tube (2.5 ml) for subsequent CMV genomic and transcriptomic studies. Cell preservation plasma and whole blood for biocollection (2 tubes EDTA de 7ml). Samples stored by the centers' virology laboratories are periodically sent to the CNR for analysis. |
- CMV infection according to criteria defined by the European EBMT group (Ljungman et al., 2017). [ Time Frame: between Day-30 and Day -8 ]CMV detection (CMV DNAemia or antigen detection) in any body fluid or tissue specimen
- CMV infection according to criteria defined by the European EBMT group (Ljungman et al., 2017). [ Time Frame: between Day-8 and Day 0 ]CMV detection (CMV DNAemia or antigen detection) in any body fluid or tissue specimen
- CMV infection according to criteria defined by the European EBMT group (Ljungman et al., 2017). [ Time Frame: at Day20 ]CMV detection (CMV DNAemia or antigen detection) in any body fluid or tissue specimen
- CMV infection according to criteria defined by the European EBMT group (Ljungman et al., 2017). [ Time Frame: at Day100 ]CMV detection (CMV DNAemia or antigen detection) in any body fluid or tissue specimen
- CMV infection according to criteria defined by the European EBMT group (Ljungman et al., 2017). [ Time Frame: at Day 200 (Month 6) ]CMV detection (CMV DNAemia or antigen detection) in any body fluid or tissue specimen
- CMV infection according to criteria defined by the European EBMT group (Ljungman et al., 2017). [ Time Frame: Month12 ]CMV detection (CMV DNAemia or antigen detection) in any body fluid or tissue specimen
- CMV infection according to criteria defined by the European EBMT group (Ljungman et al., 2017). [ Time Frame: Month24 ]CMV detection (CMV DNAemia or antigen detection) in any body fluid or tissue specimen
- Uses of anti-CMV molecules : preemptive treatment [ Time Frame: at Day200 ]% of patients having received preemptive treatment
- Uses of anti-CMV molecules : prophylaxis [ Time Frame: at Day200 ]% of patients having received prophylaxis
- Uses of anti-CMV molecules : curative treatment [ Time Frame: at Day200 ]% of patients having received curative treatment
- Uses of anti-CMV molecules [ Time Frame: at Day200 ]Cumulative duration of exposure (number of day) for each drug administered
- Uses of anti-CMV molecules : preemptive treatment [ Time Frame: at Month12 ]% of patients having received preemptive treatment
- Uses of anti-CMV molecules : prophylaxis [ Time Frame: at Month12 ]% of patients having received prophylaxis
- Uses of anti-CMV molecules : curative treatment [ Time Frame: at Month12 ]% of patients having received curative treatment
- Uses of anti-CMV molecules [ Time Frame: at Month12 ]Cumulative duration of exposure (number of day) for each drug administered
- Uses of anti-CMV molecules : preemptive treatment [ Time Frame: at Month24 ]% of patients having received preemptive treatment
- Uses of anti-CMV molecules : prophylaxis [ Time Frame: at Month24 ]% of patients having received prophylaxis
- Uses of anti-CMV molecules : curative treatment [ Time Frame: at Month24 ]% of patients having received curative treatment
- Uses of anti-CMV molecules [ Time Frame: at Month24 ]Cumulative duration of exposure (number of day) for each drug administered
- Incidence of the non-response and resistance to antivirals with risk factors associated (virological, pharmacological, immunological). Criteria recently published by Chemaly et al. CID 2018 will be used to classify cases in [ Time Frame: at Month12 ]
Criteria recently published by Chemaly et al. CID 2018 will be used to classify cases in :
- Refractory CMV infection CMV viremia that increases after at least 2 wk of appropriately dosed antiviral therapy.
- Probable refractory CMV infection : persistent viral load after at least 2 wk of appropriately dosed antiviral therapy.
- Refractory CMV end organ disease : worsening in signs and symptoms or progression into end-organ disease after at least 2 wk of appropriately dosed antiviral therapy.
- Probable refractory CMV end-organ disease : lack of improvement in signs and symptoms after at least 2 wk of appropriately dosed antiviral drugs.
- Antiviral drug resistance : viral genetic alteration that decreases susceptibility to one or more antiviral drugs.
Resistance : presence of a resistance-related mutation by resistance genotyping of UL97, UL54, UL56, UL89, UL27 genes, carried out or validated by the Limoges Herpesviruses reference laboratory. In blood or any other sample.
- Incidence of the non-response and resistance to antivirals with risk factors associated (virological, pharmacological, immunological). Criteria recently published by Chemaly et al. CID 2018 will be used to classify cases in [ Time Frame: at Month24 ]
Criteria recently published by Chemaly et al. CID 2018 will be used to classify cases in :
- Refractory CMV infection CMV viremia that increases after at least 2 wk of appropriately dosed antiviral therapy.
- Probable refractory CMV infection : persistent viral load after at least 2 wk of appropriately dosed antiviral therapy.
- Refractory CMV end organ disease : worsening in signs and symptoms or progression into end-organ disease after at least 2 wk of appropriately dosed antiviral therapy.
- Probable refractory CMV end-organ disease : lack of improvement in signs and symptoms after at least 2 wk of appropriately dosed antiviral drugs.
- Antiviral drug resistance : viral genetic alteration that decreases susceptibility to one or more antiviral drugs.
Resistance : presence of a resistance-related mutation by resistance genotyping of UL97, UL54, UL56, UL89, UL27 genes, carried out or validated by the Limoges Herpesviruses reference laboratory. In blood or any other sample.
- Adverse effects leading to interruption of treatment [ Time Frame: at Month12 ]Incidence of treatment emergent adverse event as assessed by interruption of treatment
- Adverse effects leading to interruption of treatment [ Time Frame: at Month24 ]Incidence of treatment emergent adverse event as assessed by interruption of treatment
- CMV related mortality [ Time Frame: at Month12 ]Number of patients who died from CMV related desease
- CMV related mortality [ Time Frame: at Month24 ]Number of patients who died from CMV related desease
- CMV associated morbidity : delay engraftment [ Time Frame: at Month12 ]number of days bettwen graft and engraftment
- CMV associated morbidity : GVHD [ Time Frame: at Month12 ]Incidence of GVHD
- CMV associated morbidity : CMV infection/disease [ Time Frame: at Month12 ]
Incidence of CMV infection/disease (infection or disease will be combined to report this outcome).
CMV infection : positive diagnostic test (CMV culture, antigen detection or CMV PCR), in any body fluid or tissue, in the absence of symptoms.
CMV disease : CMV infection associated with end-organ disease (clinical signs and oriented virological diagnosis).
- CMV associated morbidity : delay engraftment [ Time Frame: at Month24 ]number of days bettwen graft and engraftment
- CMV associated morbidity : GVHD [ Time Frame: at Month24 ]Incidence of GVHD
- CMV associated morbidity : CMV infection/disease [ Time Frame: at Month24 ]
Incidence of CMV infection/disease (infection or disease will be combined to report this outcome).
CMV infection : positive diagnostic test (CMV culture, antigen detection or CMV PCR), in any body fluid or tissue, in the absence of symptoms.
CMV disease : CMV infection associated with end-organ disease (clinical signs and oriented virological diagnosis).
Biospecimen Retention: Samples With DNA
Samples related to the cohort :
One blood sample from the donor (only familial donors) for genetic SNPs analysis.
5 samples: D-8 (conditioning), D20, D100 (+/- 10 days), D200 (+/- 10 days), 1 year : 1 tube of 7ml of whole blood on EDTA: Biobanking of whole blood for genetic SNPs analysis (D-8) of specific transporters for GCV, and of plasma for TTV viral load at all times. Conservation of viral load monitoring remnants at the center's virology laboratory.
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Ages Eligible for Study: | 18 Years and older (Adult, Older Adult) |
Sexes Eligible for Study: | All |
Accepts Healthy Volunteers: | No |
Sampling Method: | Probability Sample |
Inclusion Criteria :
• Candidate (adult) for an allograft of hematopoietic stem cells for which a decision of transplant is made and willing to participate in the cohort.
Exclusion Criteria :
- CMV-seronegative patient receiving a negative CMV donor graft ;
- Patient having signed the consent but not grafted ;
- Patient included in a clinical study on an anti-CMV molecule ;
- Non-insured social patient ;
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT04690933
Contact: Sophie ALAIN, Pr | 05.55.05.67.24 | sophie.alain@chu-limoges.fr | |
Contact: Françoise GARNIER-GEOFFROY, CRA | Francoise.GARNIER-GEOFFROY@chu-limoges.fr |
France | |
CHU de LIMOGES | Recruiting |
Limoges, France, 87045 | |
Contact: Sophie Alain, Pr 33 5 55 05 67 28 sophie.alain@unilim.fr | |
Contact: Françoise Geoffroy-Garnier, ING françoise.garnier-geoffroy@chu-limoges.fr |
Principal Investigator: | Pascal TURLURE | Service d'Hématologie Clinique et de Thérapie Cellulaire |
Other Publications:
Responsible Party: | University Hospital, Limoges |
ClinicalTrials.gov Identifier: | NCT04690933 |
Other Study ID Numbers: |
87RI18_0011 (NAViRe) |
First Posted: | December 31, 2020 Key Record Dates |
Last Update Posted: | December 31, 2020 |
Last Verified: | September 2020 |
Individual Participant Data (IPD) Sharing Statement: | |
Plan to Share IPD: | No |
Studies a U.S. FDA-regulated Drug Product: | No |
Studies a U.S. FDA-regulated Device Product: | No |
Hematopoietic Stem Cell Transplantation Cytomegalovirus Infections Antivirals Antiviral Drug Resistance |
Cytomegalovirus Infections Infections Herpesviridae Infections DNA Virus Infections Virus Diseases |