Cytomegalovirus glycoprotein-B vaccine with MF59 adjuvant in transplant recipients: a phase 2 randomised placebo-controlled trial

Paul D Griffiths, Anna Stanton, Erin McCarrell, Colette Smith, Mohamed Osman, Mark Harber, Andrew Davenport, Gareth Jones, David C Wheeler, James O'Beirne, Douglas Thorburn, David Patch, Claire E Atkinson, Sylvie Pichon, Paul Sweny, Marisa Lanzman, Elizabeth Woodford, Emily Rothwell, Natasha Old, Ruth Kinyanjui, Tanzina Haque, Sowsan Atabani, Suzanne Luck, Steven Prideaux, Richard S B Milne, Vincent C Emery, Andrew K Burroughs, Paul D Griffiths, Anna Stanton, Erin McCarrell, Colette Smith, Mohamed Osman, Mark Harber, Andrew Davenport, Gareth Jones, David C Wheeler, James O'Beirne, Douglas Thorburn, David Patch, Claire E Atkinson, Sylvie Pichon, Paul Sweny, Marisa Lanzman, Elizabeth Woodford, Emily Rothwell, Natasha Old, Ruth Kinyanjui, Tanzina Haque, Sowsan Atabani, Suzanne Luck, Steven Prideaux, Richard S B Milne, Vincent C Emery, Andrew K Burroughs

Abstract

Background: Cytomegalovirus end-organ disease can be prevented by giving ganciclovir when viraemia is detected in allograft recipients. Values of viral load correlate with development of end-organ disease and are moderated by pre-existing natural immunity. Our aim was to determine whether vaccine-induced immunity could do likewise.

Methods: We undertook a phase-2 randomised placebo controlled trial in adults awaiting kidney or liver transplantation at the Royal Free Hospital, London, UK. Exclusion criteria were pregnancy, receipt of blood products (except albumin) in the previous 3 months, and simultaneous multiorgan transplantation. 70 patients seronegative and 70 seropositive for cytomegalovirus were randomly assigned from a scratch-off randomisation code in a 1:1 ratio to receive either cytomegalovirus glycoprotein-B vaccine with MF59 adjuvant or placebo, each given at baseline, 1 month and 6 months later. If a patient was transplanted, no further vaccinations were given and serial blood samples were tested for cytomegalovirus DNA by real-time quantitative PCR (rtqPCR). Any patient with one blood sample containing more than 3000 cytomegalovirus genomes per mL received ganciclovir until two consecutive undetectable cytomegalovirus DNA measurements. Safety and immunogenicity were coprimary endpoints and were assessed by intention to treat in patients who received at least one dose of vaccine or placebo. This trial is registered with ClinicalTrials.gov, NCT00299260.

Findings: 67 patients received vaccine and 73 placebo, all of whom were evaluable. Glycoprotein-B antibody titres were significantly increased in both seronegative (geometric mean titre 12,537 (95% CI 6593-23,840) versus 86 (63-118) in recipients of placebo recipients; p<0.0001) and seropositive (118,395; 64,503-217,272) versus 24,682 (17,909-34,017); p<0.0001) recipients of vaccine. In those who developed viraemia after transplantation, glycoprotein-B antibody titres correlated inversely with duration of viraemia (p=0.0022). In the seronegative patients with seropositive donors, the duration of viraemia (p=0.0480) and number of days of ganciclovir treatment (p=0.0287) were reduced in vaccine recipients.

Interpretation: Although cytomegalovirus disease occurs in the context of suppressed cell-mediated immunity post-transplantation, humoral immunity has a role in reduction of cytomegalovirus viraemia. Vaccines containing cytomegalovirus glycoprotein B merit further assessment in transplant recipients.

Funding: National Institute of Allergy and Infectious Diseases, Grant R01AI051355 and Wellcome Trust, Grant 078332.

Sponsor: University College London (UCL).

Copyright © 2011 Elsevier Ltd. All rights reserved.

Figures

Figure 1
Figure 1
Trial profile at the time of analysis
Figure 2
Figure 2
Geometric mean (95% CI) antibody titres measured by glycoprotein-B enzyme-linked immunoassay (A) Seronegative recipients. (B) Seropositive recipients. Tx indicates the geometric mean titres found at the time of transplantation.
Figure 3
Figure 3
Inverse correlation of titre of antibodies against glycoprotein B present at the time of transplantation with duration of viraemia after transplantation Only patients with viraemia at any time were selected for this analysis. D−=cytomegalovirus seronegative donor. R−=cytomegalovirus seronegative recipient. D+=cytomegalovirus seropositive donor. R+=cytomegalovirus seropositive recipient.
Figure 4
Figure 4
Proportion of days that patients in the three subgroups at risk of CMV infection spent with viraemia or received antiviral treatment A,B, and C show the duration of viraemia. D,E, and F show the duration of antiretroviral therapy. D+R−, D+R+, and D−R+ are three groups at risk of primary infection, reinfection, and reactivation, respectively. The numbers below each column indicate the number of patients with viraemia (or treatment) divided by the number in the subgroup. Note the different values on the Y-axes of panels A and D compared with panels B, C, E, and F. D−=cytomegalovirus seronegative donor. R−=cytomegalovirus seronegative recipient. D+=cytomegalovirus seropositive donor. R+=cytomegalovirus seropositive recipient.

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