JCM Accepts, published online ahead of print on 15 May ... · 4 Davide Abate 1*, Alda Saldan 1*,...
Transcript of JCM Accepts, published online ahead of print on 15 May ... · 4 Davide Abate 1*, Alda Saldan 1*,...
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Comparison of CMV ELISPOT and CMV QuantiferonTM interferon-γ 1
releasing assays in assessing risk of CMV infection in kidney transplant 2
recipients 3
Davide Abate1*, Alda Saldan1*, Carlo Mengoli1*, Marta Fiscon1, Cristina Silvestre2, 4
Loredana Fallico1, Marta Peracchi1, Lucrezia Furian2, Riccardo Cusinato1, Luciana 5
Bonfante3, Barbara Rossi4, Francesco Marchini4, Dino Sgarabotto5, Paolo Rigotti2, 6
Giorgio Palù1 7
8 1Department of Molecular Medicine - 2Department of Surgery, Oncology and Gastroenterology, 9
3Department of Medicine Nephrology I Unit, 4Hemodialisis and Nephrology II 5Transplant infectious 10
disease division, Padua General Hospital - University of Padua School of Medicine via Gabelli, 63 - 35121 11
Padova Italy. 12
* Authors share equal contribution. 13
14 Keywords: Human Cytomegalovirus, transplantation, T-cell immunity, ELISPOT, 15
Quantiferon 16
17 Running title: CMV ELISPOT and Quantiferon in kidney transplants 18 19 Astract: 250 words 20 Text: 2270 words 21 Figures: 3 22 Tables: 4 23 24 Corresponding author: 25
Dr. Davide Abate 26 Department of Molecular Medicine 27 University of Padova 28 Via Gabelli, 63 35121 29 Padova Italy. 30 Phone: +39 0498218940 31 Fax: +39 0498216379 32 E-mail: [email protected] 33 34
Copyright © 2013, American Society for Microbiology. All Rights Reserved.J. Clin. Microbiol. doi:10.1128/JCM.00563-13 JCM Accepts, published online ahead of print on 15 May 2013
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Abstract 35
Background. Assessing the CMV specific cell-mediated immunity (CMI) represents an 36
appealing strategy to detect transplant recipients at risk of infection. In this study we 37
compared two interferon gamma-releasing assays (IGRAs), CMV Quantiferon and CMV 38
ELISPOT, in predicting protective CMV specific T-cell responses. 39
Methods. 221 Quantiferon and ELISPOT tests were conducted on 120 adult KTR 40
(including 100 R+ and 20 D+/R-). As control cohort 39 adult healthy subjects (including 41
33 CMV seropositive and 6 CMV seronegative) were enrolled. CMV IgG serology was 42
used as reference for both tests. 43
Results. In CMV seropositive individuals, ELISPOT and Quantiferon provided 46% 44
concordance with serology, 12% discordance, 18% disagreement between ELISPOT or 45
Quantiferon with serology and 24% grey areas when one or both tests resulted weak 46
positive. None of CMV seronegative subjects showed detectable responses in ELISPOT 47
and Quantiferon. In transplant recipients, both ELISPOT and Quantiferon positively 48
correlated with each other and negatively correlated to CMV DNAemia in a significant 49
way (p-value <0.05). During the antiviral prophylaxis, all 20 D+/R- KTRs examined 50
displayed undetectable Quantiferon and ELISPOT and there was no evidence of CMV 51
seroconversion. The ROC statistical analysis revealed similar specificity and sensitivity 52
in predicting detectable viremia (AUC 0.66 and 0.62 for Quantiferon and ELISPOT 53
respectively). ELISPOT and Quantiferon values above 150 spots/200000 PBMCs and >1-54
6 IU IFN-g were associated with protection from CMV infection (OR 5 and 8.75 55
respectively). 56
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Conclusion. In transplants both tests displayed similar ability in predicting CMV 57
infection. Both ELISPOT and Quantiferon require several ameliorations to avoid false 58
nagative results. 59
Abbreviations: KTR, kidney transplant recipients; R+, CMV seropositive transplant recipient; D+/R-, CMV 60
serogenative transplant recipient of a CMV positive donor; ROC, receiving operator characteristics; AUC, area under 61
the curve. PBMCs, peripheral blood mononuclear cells; OR, odd ratio. 62
63
Introduction 64
Human cytomegalovirus (CMV) represents one of the primary opportunistic pathogen 65
and a leading cause of morbidity and mortality in transplant subjects. The pre-emptive or 66
prophylaxis antiviral therapy has effectively reduced the impact and incidence of 67
symptomatic CMV infection, however the drug-related toxicity and the potential 68
emergence of drug resistant CMV strains discourage a prolonged antiviral regimen. 69
The cell mediated immunity (CMI), and in specific the CMV specific CD4+ and CD8+ T-70
cell response, is able to control viral replication and thus the onset of symptomatic 71
infections (9, 11, 14, 16, 24). In CMV D+/R- transplants, de novo CMI develops upon 72
primary CMV infection often originated from virus reactivation within the allograft, 73
while in CMV R+ transplants CMI recovers from previously existing immunity. The 74
assessment of CMV specific CMI has also been used to determine the individual risk of 75
infection and as a helpful indicator in making therapeutic decisions such as whether 76
initiate or terminate an antiviral treatment (1-4, 10, 13, 31). For this reason a diagnostic 77
test assessing the status of immune reconstitution has been recommended in the current 78
CMV management guidelines in transplant patients (17). 79
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At the present, several methods are available to monitor the CMI in transplant recipients: 80
several methods rely on the functional analysis of T-cell secreted cytokines or T-cell 81
phenotype (ie IFN-γ, TNF-α, IL-2, CD107a, PD-1) upon antigen stimulation, while other 82
methods, such as tetramer assays are based on direct detection of antigen specific T-cells 83
or cell proliferation assays (5, 27, 28, 32). Moreover tetramer assays are limited to few 84
human leukocyte antigen (HLA) haplotypes and thus may not be applicable to all 85
patients. Most of these methods rely on advanced technologies and costly reagents or 86
require a long turnaround time-to-result that make the test of impractical use for 87
clinical/diagnostic purposes. These issues and the lack of standardization have limited 88
their use to highly specialized laboratories. In the recent years an increasing number of 89
reports focused on IGRAs as diagnostic standard for detecting CMI towards infectious 90
agents in humans (1-3, 7, 13, 18-20). IGRA tests provide a practical, standardized, rapid 91
and cost-effective tool to assess the pathogen specific CMI (reviewed in (12, 21, 25). 92
The most commonly used IGRAs, T-SPOT TB (ELISPOT) and TB-Gold (Quantiferon), 93
were developed for detecting Mycobacterium tuberculosis (TB) responses. Both T-SPOT 94
TB and TB-Gold are FDA approved tests for use in humans and display similar 95
characteristics in assessing tuberculosis infection in immunocompetent subjects (6, 30). 96
Some reports also support that T-SPOT TB may be useful in immunosuppressed 97
population since it has higher sensitivity compared to TB-Gold (23, 26). 98
In this study we compared CMV IFN-γ ELISPOT and Quantiferon tests to assess their 99
grade of agreement, correlation and ability to predict CMV infection. Both tests have 100
been used in experimental settings to detect CMV specific T-cell responses in transplants 101
(3, 8, 15, 18, 29, 34) 102
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The main differences between CMV ELISPOT and Quantiferon include: 1) the stimulus 103
peptide composition designed to stimulate selectively CD8+ T cells (Quantiferon) or both 104
CD4+ and CD8+ T-cells (ELISPOT); 2) Quantiferon test evaluates the IFN-γ production 105
in a volume of 1ml of whole blood, while ELISPOT considers the IFN-γ production in a 106
given number of PBMCs isolated from blood; 3) Quantiferon quantitatively measures 107
IFN-γ as international units (IU), while ELISPOT quantifies the spot forming colonies 108
(SFC) produced by a given number of PBMCs; 109
110
Methods and Patients 111
Patients and definitions 112
221 ELISPOT and Quantiferon tests were performed on 125 KTRs enrolled in the study 113
from September 2009 to September 2012. As control group we enrolled also 39 adult 114
healthy subjects. The control group included 33 adult CMV IgG seropositive and 6 CMV 115
IgG seronegative healthy subjects with median age 52 (range 24-72 years old), 116
comprising 19 Caucasian male and 20 Caucasian female. 125 KTRs were voluntarily 117
recruited among the transplants subjects at 30, 60, 90, 180 and 360 days after transplant. 118
The main clinical characteristics of patients are shown in Table 1. Study exclusion 119
criteria included any condition of pre-existing or acquired immunodeficiency. The Padua 120
General hospital institutional review board and ethical committee approved all the 121
medical and diagnostic procedures. CMV seropositive recipients (R+) were treated 122
according to pre-emptive antiviral strategy once CMV DNAemia was detected >10.000 123
copies/ml of whole blood. CMV seronegative recipients of a CMV seropositive allograft 124
(D+/R-) were treated according to antiviral prophylaxis regimen for 180 days after 125
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transplant. Standard antiviral therapy comprised the administration of (val)-ganciclovir 126
(Valcyte, Roche) at standard dose (900mg per day orally) corrected for renal 127
functionality. No cases of CMV drug resistant strains occurred during the study. CMV 128
disease is defined as fever, malaise, and /or gastrointestinal symptoms with concurrent 129
CMV DNAemia and absence of other ongoing infections. 130
131
Detection of CMV viremia (DNAemia) 132
In all cases shown CMV viremia was evaluated using real time polymerase chain reaction 133
(PCR) with an Abi Prism 7900 HT (Applied Biosystems). PCR primers, probes and PCR 134
conditions were described (22). The lowest detection limit is defined as <1000 copies/ml 135
of whole blood. CMV infection is defined as two sequential episodes of CMV DNAemia 136
>1000 copies. Routine surveillance for viral reactivation or infection included weekly 137
determination of CMV DNAemia during the first 100 days after transplant and continued 138
thereafter if clinically indicated. 139
140
CMV serology 141
CMV serostatus was assessed using IgG ELISA assay (Enzygnost; Dade Behring). IgM 142
ELISA (Enzygnost; Dade Behring) was used to detect primary CMV infection. 143
144
Quantiferon and ELISPOT tests 145
Both Quantiferon and ELISPOT were performed on freshly isolated blood: at the same 146
time peripheral blood was collected in 3 (3x1ml) Quantiferon (Cellestis) tubes (Positive 147
control, negative control-nil- and CMV stimulus) and 10 mls of peripheral blood were 148
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collected in sodium citrate tubes for ELISPOT testing. Quantiferon blood tubes were 149
incubated overnight at 37°C and further processed according to manufacturer’s 150
instructions. Quantiferon data were acquired using Personal lab workstation (Adaltis). 151
For ELISPOT testing, PBMCs were extracted using Ficoll-plaque Plus gradient (GE 152
healthcare) and 200000 PBMCs/well were seeded in a 96 well ELISPOT plate (AID 153
diagnostic) and stimulated as described (3). Quantiferon and ELISPOT tests were 154
performed independently in double blind fashion. As indicated by manufacturer 155
datasheet, ELISPOT was considered positive >20 spots, while Quantiferon >0.2 IU. The 156
reported values refer to presence of CMI, not to protection from infection. 157
158
Statistical analysis 159
Stata software (StataCorp) was used to analyze the data. The correlation of ELISPOT to 160
Quantiferon and CMV DNAemia was obtained by negative binomial regression where 161
ELISPOT was expressed as number of spots, Quantiferon as IFN-γ cytokine 162
concentration, and CMV DNAemia was a binary (0, 1) variable. 163
ELISPOT and Quantiferon were evaluated by receiving operator curve (ROC) analysis, 164
using as endpoint (reference variable) the protection against the emergence of an episode 165
of detectable CMV viremia. Sensitivity and specificity were obtained for every possible 166
cutoff of the ELISPOT or Quantiferon. The overall odds ratio (OR) was calculated as: 167
sensitivity*specificity/[(1-sensitivity)*(1-specificity)]. 168
We considered ELISPOT and Quantiferon levels protective if no detectable events of 169
CMV DNAemia occurred within 60 days after ELISPOT and Quantiferon determination. 170
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Given the low number of D+/R- patients analyzed, the statistical analysis to assess the 171
Quantiferon and ELISPOT ability to predict viremia was not possible. 172
173
174
Results 175
Quantiferon and ELISPOT in respect to CMV IgG serology in healthy adult individuals 176
We compared the results of Quantiferon and ELISPOT in a cohort of 39 controls 177
including 33 CMV IgG positive and 6 IgG negative subjects. None of these subjects 178
resulted positive for CMV IgM. In 6/6 CMV IgG seronegative controls both Quantiferon 179
and ELISPOT displayed undetectable values, in accordance with negative serology. 180
Of the 33 IgG seropositive healthy subjects analyzed, 4/33 (12%) displayed undetectable 181
CMI both with Quantiferon and ELISPOT, 15/33 (46%) resulted with positive CMI both 182
for Quantiferon and ELISPOT (>40 spot and >0.3 IU IFN-γ), while in 6/33 (18%) 183
ELISPOT and Quantiferon were discordant (4 ELISPOT +/ Quantiferon - and 2 184
ELISPOT - / Quantiferon +) and in 8/33 (24%) ELISPOT or Quantiferon displayed 185
borderline weak positive value (table 2). The 4/33 (12%) subjects displaying undetectable 186
CMI in Quantiferon and ELISPOT in disagreement with positive CMV IgG serology 187
produced detectable high responses in ELISPOT when stimulated with whole CMV 188
virion lysate (data not shown). 189
Quantiferon and ELISPOT in kidney transplants 190
A total 221 Quantiferon and ELISPOT tests were performed in a cohort of 120 kidney 191
transplants including adult 100 CMV R+ and 20 CMV D+/R-. ELISPOT and Quantiferon 192
analysis was performed at 30, 60, 90, 180 and 360 days after transplant. 193
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In the group of 20 D+/R- all subjects analyzed displayed undetectable Quantiferon and 194
ELISPOT and resulted with negative CMV IgG and IgM serology throughout the 195
antiviral prophylaxis regimen. 196
In the group of 100 CMV R+ the time course of ELISPOT and Quantiferon revealed a 197
consistent increase over time that peaked at 180 days after transplant, followed by a slight 198
decrease at 360 days (figure 1). 199
Correlation of Quantiferon and ELISPOT and development of CMV DNAemia 200
In order to assess the correlation of Quantiferon and ELISPOT in transplants and the 201
relationship of Quantiferon and ELISPOT with CMV DNAemia we employed a negative 202
binomial regression statistical test. The results show that there is a statistical significant 203
correlation between Quantiferon and ELISPOT (p <0.037) and a statistical significant 204
inverse correlation between Quantiferon and ELISPOT and development of CMV 205
DNAemia (p<0.017) (table 3 and figure 2). Since the exponentiated coefficient of 206
Quantiferon is 100.0740 = 1.076781, a one-unit increase of Quantiferon predicts a 7.7% 207
increase of ELISPOT. 208
We also attempted to correlate ELISPOT and Quantiferon with the magnitude (peak of 209
viremia) and duration (days) of viremia using a linear regression approach but no 210
significant difference was found (data not shown). The statistical analysis showed that the 211
low number of cases might have caused the lack of significance. 212
Sensibility and specificity of Quantiferon and ELISPOT 213
In order to assess the sensitivity and specificity of Quantiferon and ELISPOT in 214
preventing the onset of CMV DNAemia we employed the ROC statistical analysis (figure 215
3A-B). The calculated OR for ELISPOT was 2.12. The maximum OR value observed for 216
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ELISPOT was 5.01, at cutoff values ≥ 147. However, the OR mostly exceeded 4 in the 217
cut-off area ≥ 119 - ≥ 165. The Quantiferon calculated OR was 2.52. The maximum 218
value observed for OR was 8.75, at cutoff ≥ 6.1. However, this cutoff is very high, and 219
presumably not really useful, implying a low sensitivity of 19.13%. The ROC area, 220
standard error and 95% confidence interval for Quantiferon and ELISPOT are reported in 221
table 4. We also tested if the combining both ELISPOT and Quantiferon tests increases 222
the ROC area. As shown in figure 3C, the combination of both tests results in a modest 223
increase on the ROC area (0.67). 224
225
Discussion 226
Predicting the risk of infection in transplant recipients represents an innovative and 227
promising strategy to improve the clinical management of transplant recipients. 228
In this study we present the results of a comparative analysis of two IGRA tests, 229
ELISPOT and Quantiferon, widely used to assess the CMI in transplants. 230
In healthy CMV seronegative adult subjects both Quantiferon and ELISPOT were in 231
agreement with the negative IgG serology, while in CMV IgG seropositive adults 12% of 232
subjects resulted negative for both tests. This finding was unexpectedly high given 233
previous reports (34) showing a 97% agreement with serology: the negative results of 234
Quantiferon and ELISPOT opposing the positive CMV serology in healthy individuals 235
may probably depend on previously shown inability of certain individuals in recognizing 236
pp65 (ppUL83) stimulus peptide (33) or probably to atypical or non-common HLA 237
haplotypes of these subjects (Abate et. al. submitted). Indeed CMV IgG+ individuals with 238
negative CMI in Quantiferon and ELISPOT produced positive detectable high responses 239
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when stimulated with not-HLA restricted whole CMV virion lysate (data not shown), 240
suggesting a limitation of the currently used stimuli in being recognized from 241
heterogeneous HLA types. The consistency of the results from healthy subjects should be 242
taken in account when immune monitoring is performed in transplants, in particular when 243
a negative result is obtained. In transplant subjects we have found that none of the D+/R- 244
receiving antiviral prophylaxis therapy resulted positive for Quantiferon, ELISPOT and 245
CMV IgG or IgM. This finding suggests that the current antiviral prophylaxis scheme is 246
highly effective in suppressing CMV reactivation from the allograft. This finding is also 247
consistent with previously published data on D+/R- kidney transplants being unable to 248
mount virus specific immune responses during the antiviral prophylaxis regimen (3). In 249
transplants, Quantiferon and ELISPOT displayed a positive statistical significant 250
correlation between the each other. Quantiferon and ELISPOT also showed a consistent 251
increase over time peaking at 180 days after transplant, followed by a decrease at 360 252
days: this may suggest either a general slow process of immune reconstitution boosted by 253
early post transplant episodes of CMV viremias, succeeding a steady state level of 254
antiviral immunity. 255
In transplant subjects both Quantiferon and ELISPOT displayed similar robustness 256
sensitivity and specificity and inverse correlation with development of CMV viremia 257
suggesting that values >150 spots/200000 PBMCs for ELISPOT and >1-6 IU IFN-γ for 258
Quantiferon may have good predictive value for protection from CMV viremia. The 259
proposed cutoffs refer to protection from CMV viremia and are different from the cutoff 260
of presence/absence of CMI proposed from the Quantiferon and ELISPOT 261
manufacturers. This study to our knowledge is the first comparison of Quantiferon and 262
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ELISPOT in transplants and the results from the present study may better aid clinicians to 263
understand the limitations and the advantages of the two IGRA tests analyzed. This study 264
has also elucidated some critical aspects that may be improved for both tests: there is an 265
urgent need to overcome the unexpected high number of false negative results due to 266
HLA type inability to recognize the CMV stimulus composition. 267
268
Acknowledgements 269
We are grateful to Padua General Hospital - Azienda Ospedaliera di Padova for providing 270
us the IFN-γ ELISPOT plates and Cellestis and A.D.A, Italy, for providing Quantiferon 271
and control tubes and reagents. We thank Daniel Tinto, Alice Bianchin, Angela Bozza, 272
Simona Cofano and Valentina Fornasiero for the technical guidance. We also want to 273
thank Elisa Sefora Pierobon and Margherita Moro for medical advice. 274
275
Authors’ contribution 276
DA, CM, DS, PR, GP analyze the statistical data and wrote the manuscript. AS, LF, MP, 277
MF performed the tests and collected the experimental data. DA, LF, CS, PR, RC, LB, 278
RB, MF, DS, CM, GP supervised the clinical study. 279
280
Conflict of interests 281
The authors declare no conflict of interest. 282
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Figure and figure legend 289
Figure 1 290 A 291
292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 B 307 308
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Figure 1. ELISPOT (A) and Quantiferon (B) regression over time after transplant in 312 CMV R+ subjects. Hallow circles represent single observations. A “Lowess smoother” 313 (a locally weighted regression line, dashed line) was added for clarity. 314
315
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Figure 2 316
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QUANTIFERON
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Figure 2. The fitted values of ELISPOT score (predictions of the negative binomial model) are indicated as 318 two lines, assuming an undetectable CMV DNAemia (dashed line) or a detectable CMV DNAemia (solid 319 line). Hollow diamonds indicate the individual observations. 95% confidence intervals for the predictions 320 are also indicated. ELISPOT values were limited to the scale 0–400, Quantiferon to 0-10. 321
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Figure 3 334
A 335
B
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False positive rate
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C 341
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False positive rate
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343 Figure 3. ROC curve analysis using only (A) Quantiferon (black solid dots, AUC = 0.6604) or (B) 344 ELISPOT (gray hollow dots, AUC = 0.6203) or (C) both tests in combination (AUC = 0.6731). The 345 endpoint (reference variable) was the protection against the emergence of an episode of CMV viremia. The 346 Quantiferon or ELISPOT scores were the classifying variables. Numbers on the curve represent the 347 absolute Quantiferon or ELISPOT values. 348 349 350
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Table 1. Transplants characteristics 359
Patient’s characteristics KTRs (%)Total n. 120 Gender Male (%) 82 (71) Female (%) Age (median, range)
38 (29) 53 (21-82)
CMV serostatus D+/R+ and D-/R+ (%) 100 (83) D+/R- (%) 20 (17) Immunosuppressive regimen CNI, MMF, and steroids (%) 120 (100) Acute rejection episodes (%) 26 (22) Patients who experienced post-transplant CMV DNAemia All (%) 53 (44) R+ (%) 47 (89) R- (%) 6 (11) Patients with CMV disease All (%) 2 (2) R+ (%) 1 (50) R- (%) 1 (50) Patients who received treatment for CMV infection All (%) 32 (27) R+ (%) 27 (84) R- (%) 5 (16)
Abbreviations: CNI, calcineurin inhibitors; MMF, mycophenolate mofetil; mTOR, mammalian target or 360 rapamycin. 361 362
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Table 2. ELISPOT and Quantiferon test in CMV IgG+ individuals 372
HS (%) ELISPOT Quantiferon15 (46%) Pos Pos 4 (12%) Neg Neg 4 (12%) Pos Neg 2 (6%) Neg Pos 4 (12%) Weak Pos Pos 1 (3%) Weak Pos Weak Pos 3 (9%) Pos Weak Pos
HS: healthy subjects; Positive values: ELISPOT >40, Quantiferon >0.3; Negative 373 values: ELISPOT <20, Quantiferon <0.2; Weak positives: ELISPOT >20-40<; 374 Quantiferon >0.2-0.3<. ELISPOT is expressed as number of spots/200.000 PBMCs; 375 Quantiferon as IU IFN-g 376 377
378
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Table 3. Negative binomial regression of ELISPOT versus Quantiferon and CMV 380 DNAemia in kidney transplants. 381
382
Log likelihood = -1168.0423. LR chi2(2) = 11.00. Prob > chi2 = 0.0041 383 384 385 386 387 Table 4. ELISPOT and Quantiferon ROC 388
ROC Asymptotic Normal
Area Std. Err 95% Conf. Interval
ELISPOT 0.6203 0.0458 0.53048 0.7101
Quantiferon 0.6604 0.0447 0.57285 0.74797
ELISPOT and Quantiferon score as a predictor of CMV viremia episode avoidance (protection), ROC 389 curve method. The area under the curve (AUC) is reported, along with the standard error and the 95% 390 confidence interval. 391
392
393
ELISPOT Coefficient Std. Err. z P 95% Conf. Interval
QUANTIFERON 0.0740 0.0355 2.09 0.037 0.0045 0.1435
CMV DNAemia -0.7020 0.2946 -2.38 0.017 -1.2794 -0.1245
incept 4.6125 0.1448 31.85 0.000 4.3287 4.8963
Alpha 2.674709 0.2339 2.253408 3.174776
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Comparison of Cytomegalovirus (CMV) Enzyme-LinkedImmunosorbent Spot and CMV Quantiferon Gamma Interferon-Releasing Assays in Assessing Risk of CMV Infection in KidneyTransplant Recipients
Davide Abate,a Alda Saldan,a Carlo Mengoli,a Marta Fiscon,a Cristina Silvestre,b Loredana Fallico,a Marta Peracchi,a Lucrezia Furian,b
Riccardo Cusinato,a Luciana Bonfante,c Barbara Rossi,d Francesco Marchini,d Dino Sgarabotto,e Paolo Rigotti,b Giorgio Palùa
Department of Molecular Medicine,a Department of Surgery, Oncology and Gastroenterology,b Department of Medicine Nephrology I Unit,c Hemodialysis andNephrology II Unit,d and Transplant Infectious Disease Division,e Padua General Hospital, University of Padua School of Medicine, Padua, Italy
Volume 51, no. 8, p. 2501–2507, 2013. Page 2502, Materials and Methods, “Patients and definitions” section, line 2: “125 kidneytransplant recipients” should read “120 kidney transplant recipients.”
Page 2502, Materials and Methods, “Patients and definitions” section, line 7: “One hundred twenty-five KTRs” should read “Onehundred twenty KTRs.”
Page 2502, Materials and Methods, “Patients and definitions” section: Information about the transplant immunosuppression inductionprotocol used was inadvertently omitted. The following statement should be inserted at the end of line 9: “The following inductionimmunosuppressive treatments were employed: antithymocyte globulin (ATG) for 67/120 patients (56%) (median age of cohort, 60years), basiliximab for 47/120 patients (39%) (median age of cohort, 48 years), both ATG and basiliximab for 3/120 patients (2.5%)(median age of cohort, 34 years), and alefacept for 3/120 patients (2.5%) (median age of cohort, 33 years).” The overall results andconclusions of the study are unchanged.
Copyright © 2014, American Society for Microbiology. All Rights Reserved.
doi:10.1128/JCM.00110-14
AUTHOR CORRECTION
March 2014 Volume 52 Number 3 Journal of Clinical Microbiology p. 1025 jcm.asm.org 1025