{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T07:50:06Z","timestamp":1785570606747,"version":"3.56.0"},"reference-count":45,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2021,11,26]],"date-time":"2021-11-26T00:00:00Z","timestamp":1637884800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001659","name":"Deutsche Forschungsgemeinschaft","doi-asserted-by":"publisher","award":["FU 356\/12-1"],"award-info":[{"award-number":["FU 356\/12-1"]}],"id":[{"id":"10.13039\/501100001659","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100002347","name":"Federal Ministry of Education and Research","doi-asserted-by":"publisher","award":["031L0027D"],"award-info":[{"award-number":["031L0027D"]}],"id":[{"id":"10.13039\/501100002347","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cells"],"abstract":"<jats:p>The incidence and severity of viral complications after cellular therapy are highly variable. Recent publications describe relevant interactions between the human Cytomegalovirus (CMV) and host immunity in recipients of allogeneic hematopoietic cell transplantation (HCT). Although immune monitoring is routinely performed in HCT patients, validated cut-off levels correlating with transplant outcomes such as survival or CMV reactivation are mostly limited to day +100, which is later than the median time for CMV reactivation in the absence of medical prophylaxis. To address this gap in early risk assessment, we applied an unsupervised machine learning technique based on clustering of day +30 CD4+ helper T cell count data, and identified relevant cut-off levels within the diverse spectrum of early CD4+ reconstitution. These clusters were stratified for CMV recipient serostatus to identify early risk groups that predict clinical HCT outcome. Indeed, the new risk groups predicted subsequent clinical events such as NRM, OS, and high CMV peak titers better than the most established predictor, i.e., the positive CMV recipient serostatus (R+). More specifically, patients from the R+\/low CD4+ subgroup strongly associated with high CMV peak titers and increased 3-year NRM (subdistribution hazard ratio (SHR) 10.1, 95% CI 1.38\u201373.8, p = 0.023), while patients from the R-\/very high CD4+ subgroup showed comparable NRM risks (SHR 9.57, 95% CI 1.12\u201381.9, p = 0.039) without such an association. In short, our study established novel cut-off levels for early CD4+ T cells via unsupervised learning and supports the integration of host cellular immunity into clinical risk-assessment after HCT in the context of CMV reactivation.<\/jats:p>","DOI":"10.3390\/cells10123318","type":"journal-article","created":{"date-parts":[[2021,11,28]],"date-time":"2021-11-28T22:19:16Z","timestamp":1638137956000},"page":"3318","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Combined Analysis of Early CD4+ T Cell Counts and CMV Serostatus May Improve CMV Risk Assessment after Allogeneic Hematopoietic Cell Transplantation"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4956-1760","authenticated-orcid":false,"given":"Saskia","family":"Leserer","sequence":"first","affiliation":[{"name":"Computational Hematology Lab, Department of Hematology and Stem Cell Transplantation, University Hospital Essen, 45122 Essen, Germany"},{"name":"Department of Hematology and Stem Cell Transplantation, University Hospital Essen, 45122 Essen, Germany"},{"name":"Institute for Experimental Cellular Therapy, University Hospital Essen, 45122 Essen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3696-5803","authenticated-orcid":false,"given":"Esteban","family":"Arrieta-Bola\u00f1os","sequence":"additional","affiliation":[{"name":"Institute for Experimental Cellular Therapy, University Hospital Essen, 45122 Essen, Germany"},{"name":"German Cancer Consortium (DKTK), Partner Site Essen\/D\u00fcsseldorf, 45147 Essen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ulrike","family":"Buttkereit","sequence":"additional","affiliation":[{"name":"Department of Hematology and Stem Cell Transplantation, University Hospital Essen, 45122 Essen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dietrich W.","family":"Beelen","sequence":"additional","affiliation":[{"name":"Department of Hematology and Stem Cell Transplantation, University Hospital Essen, 45122 Essen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1347-3360","authenticated-orcid":false,"given":"Amin T.","family":"Turki","sequence":"additional","affiliation":[{"name":"Computational Hematology Lab, Department of Hematology and Stem Cell Transplantation, University Hospital Essen, 45122 Essen, Germany"},{"name":"Department of Hematology and Stem Cell Transplantation, University Hospital Essen, 45122 Essen, Germany"},{"name":"Institute for Experimental Cellular Therapy, University Hospital Essen, 45122 Essen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1619","DOI":"10.1182\/blood.2019000956","article-title":"How I treat CMV reactivation after allogeneic hematopoietic stem cell transplantation","volume":"135","author":"Einsele","year":"2020","journal-title":"Blood"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2433","DOI":"10.1056\/NEJMoa1706640","article-title":"Letermovir Prophylaxis for Cytomegalovirus in Hematopoietic-Cell Transplantation","volume":"377","author":"Marty","year":"2017","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1038\/ng.3822","article-title":"Immunosequencing identifies signatures of cytomegalovirus exposure history and HLA-mediated effects on the T cell repertoire","volume":"49","author":"Emerson","year":"2017","journal-title":"Nat. Genet."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"3835","DOI":"10.1182\/blood-2015-03-631853","article-title":"CMV reactivation drives post-transplant T cell reconstitution and results in defects in the underlying TCR\u03b2 repertoire","volume":"125","author":"Suessmuth","year":"2015","journal-title":"Blood"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1002\/ajh.26094","article-title":"Cytomegalovirus kinetics after hematopoietic cell transplantation reveal peak titers with differential impact on mortality, relapse and immune reconstitution","volume":"96","author":"Leserer","year":"2021","journal-title":"Am. J. Hematol."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Duke, E.R., Williamson, B.D., Borate, B., Golob, J.L., Wychera, C., Stevens-Ayers, T., Huang, M.-L., Cossrow, N., Wan, H., and Mast, T.C. (2021). CMV viral load kinetics as surrogate endpoints after allogeneic transplantation. J. Clin. Investig., 131.","DOI":"10.1172\/JCI133960"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1093\/infdis\/jiab212","article-title":"Cytomegalovirus Viral Load Kinetics Predict Cytomegalovirus End-Organ Disease and Mortality After Hematopoietic Cell Transplant","volume":"224","author":"Stern","year":"2021","journal-title":"J. Infect. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1182\/bloodadvances.2020002735","article-title":"Adoptive therapy with CMV-specific cytotoxic T lymphocytes depends on baseline CD4+ immunity to mediate durable responses","volume":"5","author":"Fabrizio","year":"2021","journal-title":"Blood Adv."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2427","DOI":"10.1182\/blood-2015-11-679639","article-title":"Early cytomegalovirus reactivation remains associated with increased transplant-related mortality in the current era: A CIBMTR analysis","volume":"127","author":"Teira","year":"2016","journal-title":"Blood"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1093\/cid\/ciu364","article-title":"Donor Cytomegalovirus Status Influences the Outcome of Allogeneic Stem Cell Transplant: A Study by the European Group for Blood and Marrow Transplantation","volume":"59","author":"Ljungman","year":"2014","journal-title":"Clin. Infect. Dis."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1016\/j.bbmt.2012.10.010","article-title":"Immune Reconstitution Kinetics as an Early Predictor for Mortality using Various Hematopoietic Stem Cell Sources in Children","volume":"19","author":"Bartelink","year":"2013","journal-title":"Biol. Blood Marrow Transplant."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1182\/blood.V93.2.467","article-title":"Comparison of Immune Reconstitution after Unrelated and Related T-Cell\u2013Depleted Bone Marrow Transplantation: Effect of Patient Age and Donor Leukocyte Infusions","volume":"93","author":"Small","year":"1999","journal-title":"Blood"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"507","DOI":"10.3389\/fimmu.2016.00507","article-title":"Immune Reconstitution after Allogeneic Hematopoietic Stem Cell Transplantation","volume":"7","author":"Ogonek","year":"2016","journal-title":"Front. Immunol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2734","DOI":"10.1182\/blood-2016-06-721936","article-title":"Excellent T-cell reconstitution and survival depend on low ATG exposure after pediatric cord blood transplantation","volume":"128","author":"Admiraal","year":"2016","journal-title":"Blood"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"848","DOI":"10.1182\/blood.2020007905","article-title":"CD4+ T-cell reconstitution predicts survival outcomes after acute graft-versus-host-disease: A dual-center validation","volume":"137","author":"Prockop","year":"2021","journal-title":"Blood"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"2250","DOI":"10.1182\/bloodadvances.2018029892","article-title":"Kinetics of immune cell reconstitution predict survival in allogeneic bone marrow and G-CSF\u2013mobilized stem cell transplantation","volume":"3","author":"Waller","year":"2019","journal-title":"Blood Adv."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1056\/NEJM198603203141201","article-title":"Methotrexate and Cyclosporine Compared with Cyclosporine Alone for Prophylaxis of Acute Graft versus Host Disease after Marrow Transplantation for Leukemia","volume":"314","author":"Storb","year":"1986","journal-title":"N. Engl. J. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1097\/00007890-199009000-00013","article-title":"Six Weeks of Continuous Intravenous Cyclosporine and Short-Course Methotrexate as Prophylaxis for Acute Graft-Versus-Host Disease after Allogeneic Bone Marrow Transplantation","volume":"50","author":"Beelen","year":"1990","journal-title":"Transplantation"},{"key":"ref_19","first-page":"825","article-title":"1994 Consensus Conference on Acute GVHD Grading","volume":"15","author":"Przepiorka","year":"1995","journal-title":"Bone Marrow Transplant."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1080\/01621459.1958.10501452","article-title":"Nonparametric Estimation from Incomplete Observations","volume":"53","author":"Kaplan","year":"1958","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1111\/j.2517-6161.1972.tb00899.x","article-title":"Regression Models and Life-Tables","volume":"34","author":"Cox","year":"1972","journal-title":"J. R. Stat. Soc. Series B Stat. Methodol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1080\/01621459.1999.10474144","article-title":"A Proportional Hazards Model for the Subdistribution of a Competing Risk","volume":"94","author":"Fine","year":"1999","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_23","unstructured":"(2021). R: A Language and Environment for Statistical Computing, R Core Team, R Foundation for Statistical Computing. version 4.0.4."},{"key":"ref_24","unstructured":"Therneau, T. (2021). A Package for Survival Analysis in R, R Foundation for Statistical Computing. version 3.2-11."},{"key":"ref_25","unstructured":"Kassambara, A., Kosinski, M., and Biecek, P. (2021). Survminer: Drawing Survival Curves Using \u2032ggplot2\u2032, R Foundation for Statistical Computing. R package version 0.4.9."},{"key":"ref_26","unstructured":"Gray, B. (2020). cmprsk: Subdistribution Analysis of Competing Risks, R Foundation for Statistical Computing. R package version 2.2-10."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Wickham, H. (2016). ggplot2: Elegant Graphics for Data Analysis, Springer.","DOI":"10.1007\/978-3-319-24277-4_9"},{"key":"ref_28","first-page":"3359","article-title":"CMV serostatus still has an important prognostic impact in de novo acute leukemia patients after allogeneic stem cell transplantation: A report from the Acute Leukemia Working Party of EBMT","volume":"122","author":"Labopin","year":"2013","journal-title":"Blood"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.1038\/sj.bmt.1705381","article-title":"Rapid helper T-cell recovery above 200 x 10 6\/l at 3 months correlates to successful transplant outcomes after allogeneic stem cell transplantation","volume":"37","author":"Kim","year":"2006","journal-title":"Bone Marrow Transplant."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1450","DOI":"10.1038\/s41409-018-0172-y","article-title":"Early human cytomegalovirus reactivation is associated with lower incidence of relapse of myeloproliferative disorders after allogeneic hematopoietic stem cell transplantation","volume":"53","author":"Peric","year":"2018","journal-title":"Bone Marrow Transplant."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1643","DOI":"10.1016\/j.jaci.2016.12.992","article-title":"Viral reactivations and associated outcomes in the context of immune reconstitution after pediatric hematopoietic cell transplantation","volume":"140","author":"Admiraal","year":"2017","journal-title":"J. Allergy Clin. Immunol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1182\/bloodadvances.2017014464","article-title":"Delayed immune reconstitution after allogeneic transplantation increases the risks of mortality and chronic GVHD","volume":"2","author":"Bejanyan","year":"2018","journal-title":"Blood Adv."},{"key":"ref_33","first-page":"174","article-title":"The impact of early CD4+ lymphocyte recovery on the outcome of patients who undergo allogeneic bone marrow or peripheral blood stem cell transplantation","volume":"10","author":"Fedele","year":"2012","journal-title":"Blood Transfus."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1016\/j.jcyt.2020.05.005","article-title":"Early CD4+ T cell reconstitution as predictor of outcomes after allogeneic hematopoietic cell transplantation","volume":"22","author":"Prockop","year":"2020","journal-title":"Cytotherapy"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e194","DOI":"10.1016\/S2352-3026(15)00045-9","article-title":"Association between anti-thymocyte globulin exposure and CD4+ immune reconstitution in paediatric haemopoietic cell transplantation: A multicentre, retrospective pharmacodynamic cohort analysis","volume":"2","author":"Admiraal","year":"2015","journal-title":"Lancet Haematol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1186","DOI":"10.3389\/fmicb.2019.01186","article-title":"Human Cytomegalovirus Latency and Reactivation in Allogeneic Hematopoietic Stem Cell Transplant Recipients","volume":"10","author":"Stern","year":"2019","journal-title":"Front. Microbiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"79","DOI":"10.3389\/fimmu.2017.00079","article-title":"Pathophysiology of GvHD and Other HSCT-Related Major Complications","volume":"8","author":"Ghimire","year":"2017","journal-title":"Front. Immunol."},{"key":"ref_38","first-page":"677","article-title":"Optimizing anti-T-lymphocyte globulin dosing to improve long-term outcome after unrelated hematopoietic cell transplantation for hematologic malignancies","volume":"20","author":"Turki","year":"2019","journal-title":"Arab. Archaeol. Epigr."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1126\/science.aat0066","article-title":"Strain-specific antibody therapy prevents cytomegalovirus reactivation after transplantation","volume":"363","author":"Martins","year":"2019","journal-title":"Science"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1200\/JCO.2008.16.8450","article-title":"Immunoglobulin Prophylaxis in Hematopoietic Stem Cell Transplantation: Systematic Review and Meta-Analysis","volume":"27","author":"Raanani","year":"2009","journal-title":"J. Clin. Oncol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1143","DOI":"10.1016\/j.bbmt.2009.06.019","article-title":"Guidelines for Preventing Infectious Complications among Hematopoietic Cell Transplantation Recipients: A Global Perspective","volume":"15","author":"Tomblyn","year":"2009","journal-title":"Biol. Blood Marrow Transplant."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1038\/nri3152","article-title":"Expanding roles for CD4+ T cells in immunity to viruses","volume":"12","author":"Swain","year":"2012","journal-title":"Nat. Rev. Immunol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1755","DOI":"10.1007\/s00277-019-03669-z","article-title":"The prognostic impact of the cytomegalovirus serostatus in patients with chronic hematological malignancies after allogeneic hematopoietic stem cell transplantation: A report from the Infectious Diseases Working Party of EBMT","volume":"98","author":"Tridello","year":"2019","journal-title":"Ann. Hematol."},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"Sammut, C., and Webb, G.I. (2016). ROC Analysis. Encyclopedia of Machine Learning and Data Mining, Springer.","DOI":"10.1007\/978-1-4899-7687-1"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1038\/sj.bmt.1704084","article-title":"A comparison of T-, B- and NK-cell reconstitution following conventional or nonmyeloablative conditioning and transplantation with bone marrow or peripheral blood stem cells from human leucocyte antigen identical sibling donors","volume":"32","author":"Petersen","year":"2003","journal-title":"Bone Marrow Transplant."}],"container-title":["Cells"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2073-4409\/10\/12\/3318\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:36:08Z","timestamp":1760168168000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2073-4409\/10\/12\/3318"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,26]]},"references-count":45,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2021,12]]}},"alternative-id":["cells10123318"],"URL":"https:\/\/doi.org\/10.3390\/cells10123318","relation":{},"ISSN":["2073-4409"],"issn-type":[{"value":"2073-4409","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,26]]}}}