Editor’s Note:
In this exclusive interview with Infectious Diseases Frontier, Professor Simone Cesaro, a leading expert in pediatric hematology and stem cell transplantation, shares his perspectives on the management of BK polyomavirus-associated hemorrhagic cystitis (HC) following hematopoietic cell transplantation (HCT). Drawing from the findings of a recent EBMT survey, he discusses the clinical implications of passive surveillance strategies, platelet transfusion thresholds, and the urgent need for consensus guidelines to support transplant centers across Europe. His insights underscore the importance of early intervention and standardization in addressing this often-overlooked complication.Infectious Diseases Frontier: Why did you choose to conduct this study in the form of a “questionnaire”?
Dr. Simone Cesaro: The reason why we use a questionnaire was to make an investigation among the practices of the EBMT centers. It was not a formal study, but just to see if the practice of EBMT centers that were mainly in Europe were according with the recommendation or there were other practices that we didn’t know.
Infectious Diseases Frontier: The data from this survey showed that only 14% of transplant centers routinely screened for BK polyoma virus (BKPyV) infection prior to hematopoietic cell transplantation (HCT), while 93% relied on post-transplantation surveillance for diagnosis. Does this ”passive surveillance” strategy delay early intervention for hemorrhagic cystitis (HC)? Would you recommend incorporating BKPyV screening into the routine pre-transplant process?
Dr. Simone Cesaro: Yeah, the problem here is to try to anticipate as soon as possible the diagnosis of BK virus-related hemorrhagic cystitis. So, regarding the practice at my center, I monitor the patient during the first phase, especially during the first months of transplant—first or second month. Because if I see an increase in the positivity for BK virus by PCR, or an increase in viral load, I can detect the first signs of hemorrhagic cystitis—pain or macroscopic hematuria. I start as soon as possible to inform the authorities because I think that early treatment is very important to avoid progression to severe forms of hemorrhagic cystitis, like grade 3 or grade 4, which are very uncomfortable and painful for the patient.
Infectious Diseases Frontier: Studies have noted a “high degree of heterogeneity” in the management of HC, e.g. platelet transfusion thresholds (30 vs. 50×109/L), cidofovir administration (intravenous vs. intravesical), etc. Is this reflective of the evidence-based nature of the field? Does this reflect a lack of evidence-based medicine in this area, and does the EBMT Infectious Diseases Working Group plan to promote expert consensus on HC management?
Dr. Simone Cesaro: I think there are no specific guidelines about this problem. The right threshold for platelet transfusion in this field, or for the management of this complication, remains unclear. It is a very niche complication, limited to patients that undergo bone marrow transplantation. But in general, I think that for every patient who has a bleeding situation, it is important to increase the level of platelets. For example, when you need to perform surgical intervention in patients who have a low platelet count, you maintain the platelet level above 50,000 through transfusion. So I think that limiting the threshold of 30,000 is the minimum that you must do. And if you are able, using the threshold of 50,000 is very important to try to block the bleeding, at least in the first week after the start of this complication.
Dr. Simone Cesaro
Graduated in Medicine in 1988 at the University of Padua. Pediatrician in 1992. I have been actively involved in pediatric hematology and oncology, especially in chemotherapy for leukemia and lymphoma, supportive care, and early and late effects of treatment, and hematopoietic stem cell transplantation (HSCT).
Appointed in 2009 Director of the Pediatric Hematology and Oncology Unit at the Department of Pediatrics in Verona. Member of the scientific committees of several working groups including Pediatrics (for MASCC), Supportive Care (for SIOP), Aplastic Anemia, Infection (for EBMT), hematopoietic stem cell transplant, Infection, Supportive care (for AIEOP). Appointed in 2005 and 2015 Chairman of the Supportive Care Group and Infection of AIEOP (Italian Association of Pediatric Hematology Oncology), respectively. Appointed in 2010, Chairman of Infectious Diseases Working Party of European Society for Blood and Marrow Transplantation.
Author of more than 200 publications in peer-reviewed journals. Medical advisor of the charities Paul O’Gorman Lifeline (UK) and Lifeline Italia, liaising with and advising pediatric hematology and oncology centers in Russia, Ukraine, Georgia and Kyrgyzstan.
