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Rethinking Antimicrobial Prophylaxis in the Transplant Patient in the World of Emerging Resistant Organisms-Where Are We Today? Curr Hematol Malig Rep 2018; 13:59-67. [PMID: 29374371 DOI: 10.1007/s11899-018-0435-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The use of prophylactic antibiotics during the neutropenic period in hematopoietic stem cell transplantation has been the standard of care at most institutions for the past 20 years. We sought to review the benefits and risks of this practice. RECENT FINDINGS Emerging data has highlighted the potential costs of antibacterial prophylaxis, from selecting for antibiotic resistance to perturbing the microbiome and contributing to increase risk for Clostridium difficile and perhaps graft-versus-host-disease, conditions which may lead to poorer outcomes. Though in many studies prophylactic antibiotics improved morbidity and mortality outcomes, the potential harms including antibiotic resistance, Clostridium difficile infection, and alterations of the gut microbiome should be considered. Future studies aimed to better risk-stratify patients and limit the use of broad-spectrum antibiotics are warranted.
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52
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Kameda K, Kimura SI, Misaki Y, Yoshimura K, Gomyo A, Hayakawa J, Tamaki M, Kusuda M, Akahoshi Y, Ugai T, Ishihara Y, Kawamura K, Sakamoto K, Tanihara A, Wada H, Sato M, Terasako-Saito K, Kikuchi M, Nakasone H, Kako S, Kanda Y. Associations between febrile neutropenia-related parameters and the risk of acute GVHD or non-relapse mortality after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2018; 54:707-716. [PMID: 30171223 DOI: 10.1038/s41409-018-0330-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/03/2018] [Accepted: 08/15/2018] [Indexed: 01/08/2023]
Abstract
Infection and inflammation can induce acute graft-vs.-host disease (aGVHD). We hypothesized that febrile neutropenia early after allogeneic hematopoietic cell transplantation (HCT) would increase the risk of aGVHD and non-relapse mortality (NRM). We retrospectively evaluated the impact of fever, C-reactive protein (CRP) concentration and blood stream infection (BSI) early after HCT on the incidence of grade II-IV aGVHD and NRM in 227 patients. Within 7 days after HCT, 91 (40.1%) patients experienced fever for at least 2 days (early-FN group). BSI occurred in 27 (11.9%) patients and the maximum CRP concentration was 2.57 mg/dl in the median. In a multivariate analysis, early-FN (hazard ratio (HR) 1.81, P = 0.007) and older recipient age (HR 1.68, P = 0.019) were significantly associated with the incidence of grade II-IV aGVHD. High-CRP and BSI were not significant risk factors for grade II-IV aGVHD. On the other hand, high-CRP was significantly associated with the incidence of NRM (HR 2.67, P = 0.004) in a multivariate analysis. In conclusion, although fever, CRP elevation and BSI are considered to be closely related events, they had different effects on the incidence of aGVHD and NRM. The development of early-FN after HCT may predict the risk of aGVHD.
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Affiliation(s)
- Kazuaki Kameda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Yukiko Misaki
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Kazuki Yoshimura
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Ayumi Gomyo
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Jin Hayakawa
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Masaharu Tamaki
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Machiko Kusuda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Yu Akahoshi
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Tomotaka Ugai
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Yuko Ishihara
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Koji Kawamura
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Kana Sakamoto
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Aki Tanihara
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Hidenori Wada
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Miki Sato
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Kiriko Terasako-Saito
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Misato Kikuchi
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Hideki Nakasone
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Shinichi Kako
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Shimotsuke, Japan.
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53
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Golob JL, Pergam SA, Srinivasan S, Fiedler TL, Liu C, Garcia K, Mielcarek M, Ko D, Aker S, Marquis S, Loeffelholz T, Plantinga A, Wu MC, Celustka K, Morrison A, Woodfield M, Fredricks DN. Stool Microbiota at Neutrophil Recovery Is Predictive for Severe Acute Graft vs Host Disease After Hematopoietic Cell Transplantation. Clin Infect Dis 2018; 65:1984-1991. [PMID: 29020185 PMCID: PMC5850019 DOI: 10.1093/cid/cix699] [Citation(s) in RCA: 125] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022] Open
Abstract
Background Graft-versus-host disease (GVHD) is common after allogeneic hematopoietic cell transplantation (HCT). Risk for death from GVHD has been associated with low bacterial diversity in the stool microbiota early after transplant; however, the specific species associated with GVHD risk remain poorly defined. Methods We prospectively collected serial weekly stool samples from 66 patients who underwent HCT, starting pre-transplantation and continuing weekly until 100 days post-transplant, a total of 694 observations in HCT recipients. We used 16S rRNA gene polymerase chain reaction with degenerate primers, followed by high-throughput sequencing to assess the relative abundance of sequence reads from bacterial taxa in stool samples over time. Results The gut microbiota was highly dynamic in HCT recipients, with loss and appearance of taxa common on short time scales. As in prior studies, GVHD was associated with lower alpha diversity of the stool microbiota. At neutrophil recovery post-HCT, the presence of oral Actinobacteria and oral Firmicutes in stool was positively correlated with subsequent GVHD; Lachnospiraceae were negatively correlated. A gradient of bacterial species (difference of the sum of the relative abundance of positive correlates minus the sum of the relative abundance of negative correlates) was most predictive (receiver operator characteristic area under the curve of 0.83) of subsequent severe acute GVHD. Conclusions The stool microbiota around the time of neutrophil recovery post-HCT is predictive of subsequent development of severe acute GVHD in this study.
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Affiliation(s)
- Jonathan L Golob
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute.,Division of Allergy and Infectious Diseases, University of Washington
| | - Steven A Pergam
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute.,Division of Allergy and Infectious Diseases, University of Washington
| | - Sujatha Srinivasan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Tina L Fiedler
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Congzhou Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Kristina Garcia
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Marco Mielcarek
- Clinical Research Division, Fred Hutchinson Cancer Institute.,Medicine
| | - Daisy Ko
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Sarah Aker
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Sara Marquis
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Tillie Loeffelholz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | | | - Michael C Wu
- Public Health Sciences Division, Fred Hutchinson Cancer Institute
| | - Kevin Celustka
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Alex Morrison
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - Maresa Woodfield
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute
| | - David N Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Institute.,Division of Allergy and Infectious Diseases, University of Washington.,Department of Microbiology, University of Washington, Seattle
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54
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Abstract
Allogeneic haematopoietic stem cell transplantation (allo-HSCT) is considered to be the strongest curative immunotherapy for various malignancies (primarily, but not limited to, haematologic malignancies). However, application of allo-HSCT is limited owing to its life-threatening major complications, such as graft-versus-host disease (GVHD), relapse and infections. Recent advances in large-scale DNA sequencing technology have facilitated rapid identification of the microorganisms that make up the microbiota and evaluation of their interactions with host immunity in various diseases, including cancer. This has resulted in renewed interest regarding the role of the intestinal flora in patients with haematopoietic malignancies who have received an allo-HSCT and in whether the microbiota affects clinical outcomes, including GVHD, relapse, infections and transplant-related mortality. In this Review, we discuss the potential role of intestinal microbiota in these major complications after allo-HSCT, summarize clinical trials evaluating the microbiota in patients who have received allo-HSCT and discuss how further studies of the microbiota could inform the development of strategies that improve outcomes of allo-HSCT.
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Affiliation(s)
- Yusuke Shono
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | - Marcel R. M. van den Brink
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Medical College of Cornell University, New York, New York, USA
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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55
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Wohlfarth P, Turki AT, Steinmann J, Fiedler M, Steckel NK, Beelen DW, Liebregts T. Microbiologic Diagnostic Workup of Acute Respiratory Failure with Pulmonary Infiltrates after Allogeneic Hematopoietic Stem Cell Transplantation: Findings in the Era of Molecular- and Biomarker-Based Assays. Biol Blood Marrow Transplant 2018; 24:1707-1714. [PMID: 29550627 PMCID: PMC7110883 DOI: 10.1016/j.bbmt.2018.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 03/06/2018] [Indexed: 12/12/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) recipients frequently develop acute respiratory failure (ARF) with pulmonary infiltrates. Molecular- and biomarker-based assays enhance pathogen detection, but data on their yield in this population are scarce. This was a retrospective single-center study of 156 consecutive HSCT recipients admitted to the intensive care unit (ICU) between May 2013 and July 2017. Findings from a microbiologic diagnostic workup using currently available methods on bronchoalveolar lavage (BAL) and blood samples from 66 patients (age, 58 years [range, 45 to 64]; HSCT to ICU, 176 days [range, 85 to 407]) with ARF and pulmonary infiltrates were analyzed. In 47 patients (71%) a causative pathogen was identified (fungal, n = 28; viral, n = 26; bacterial, n = 18). Polymicrobial findings involving several pathogen groups occurred in 20 patients (30%). Culture (12/16, 75%), galactomannan (13/15, 87%), and Aspergillus-PCR (8/9, 89%) from BAL but not serum galactomannan (6/14, 43%) helped to diagnose invasive aspergillosis (n = 16, 24%). Aspergillus-PCR detected azole resistance in 2 cases. Mucorales was found in 7 patients (11%; BAL culture, n = 6; Mucorales-PCR, n = 1). Patients with identified pathogens had higher Simplified Acute Physiology Score II scores (P = .049) and inferior ICU survival (6% versus 37%, P < .01), which largely related to the presence of an invasive fungal infection. Eight patients (12%) had 1 or more viruses with uncertain lung pathogenicity as the sole microbiologic finding. A diagnostic microbiologic workup incorporating molecular- and biomarker-based assays identified pathogens in most HSCT recipients with ARF and pulmonary infiltrates admitted to the ICU. Implications of polymicrobial infection and pathogen patterns in these patients warrant further investigation.
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Affiliation(s)
- Philipp Wohlfarth
- Department of Bone Marrow Transplantation, West German Cancer Center, University of Duisburg-Essen, University Hospital Essen, Essen, Germany; Division of Blood and Marrow Transplantation, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Amin T Turki
- Department of Bone Marrow Transplantation, West German Cancer Center, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Joerg Steinmann
- Institute of Medical Microbiology, University of Duisburg-Essen, University Hospital Essen, Essen, Germany; Institute of Clinical Hygiene, Medical Microbiology and Infectiology, Paracelsus Medical University, Nuremberg, Germany
| | - Melanie Fiedler
- Institute of Virology, University of Duisburg-Essen, Essen, Germany
| | - Nina K Steckel
- Department of Bone Marrow Transplantation, West German Cancer Center, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Dietrich W Beelen
- Department of Bone Marrow Transplantation, West German Cancer Center, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Tobias Liebregts
- Department of Bone Marrow Transplantation, West German Cancer Center, University of Duisburg-Essen, University Hospital Essen, Essen, Germany.
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56
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Andermann TM, Peled JU, Ho C, Reddy P, Riches M, Storb R, Teshima T, van den Brink MRM, Alousi A, Balderman S, Chiusolo P, Clark WB, Holler E, Howard A, Kean LS, Koh AY, McCarthy PL, McCarty JM, Mohty M, Nakamura R, Rezvani K, Segal BH, Shaw BE, Shpall EJ, Sung AD, Weber D, Whangbo J, Wingard JR, Wood WA, Perales MA, Jenq RR, Bhatt AS. The Microbiome and Hematopoietic Cell Transplantation: Past, Present, and Future. Biol Blood Marrow Transplant 2018; 24:1322-1340. [PMID: 29471034 DOI: 10.1016/j.bbmt.2018.02.009] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/08/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Tessa M Andermann
- Division of Infectious Diseases, Department of Medicine, Stanford University, Stanford, California
| | - Jonathan U Peled
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Christine Ho
- Blood and Marrow Transplantation, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Pavan Reddy
- Department of Medicine, University of Michigan Cancer Center, Ann Arbor, Michigan
| | - Marcie Riches
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Marcel R M van den Brink
- Immunology Program, Sloan Kettering Institute, New York, New York; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amin Alousi
- Multidiscipline GVHD Clinic and Research Program, Department of Stem Cell Transplant and Cellular Therapies, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sophia Balderman
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Patrizia Chiusolo
- Hematology Department, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica Sacro Cuore, Rome, Italy
| | - William B Clark
- Bone Marrow Transplant Program, Division of Hematology/Oncology and Palliative Care, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ernst Holler
- Department of Internal Medicine 3, University Medical Center, Regensburg, Germany
| | - Alan Howard
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Leslie S Kean
- Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, Washington
| | - Andrew Y Koh
- Divisions of Hematology/Oncology and Infectious Diseases, Departments of Pediatrics and Microbiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Philip L McCarthy
- Blood and Marrow Transplantation, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - John M McCarty
- Bone Marrow Transplantation Program, Virginia Commonwealth University Massey Cancer, Richmond, Virginia
| | - Mohamad Mohty
- Clinical Hematology and Cellular Therapy Department, Hôpital Saint-Antoine, AP-HP, Paris, France; Sorbonne Université, Paris, France; INSERM UMRs U938, Paris, France
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California
| | - Katy Rezvani
- Section of Cellular Therapy, Good Manufacturing Practices Facility, Department of Stem Cell Transplant and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brahm H Segal
- Department of Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; Division of Infectious Diseases, Roswell Park Comprehensive Cancer Center, Buffalo, New York; Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Bronwen E Shaw
- Center for International Blood and Bone Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Elizabeth J Shpall
- Cell Therapy Laboratory and Cord Blood Bank, Department of Stem Cell Transplantation and Cellular Therapy, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Duke Cancer Institute, Durham, North Carolina
| | - Daniela Weber
- Department of Internal Medicine 3, University Medical Center, Regensburg, Germany
| | - Jennifer Whangbo
- Dana-Farber Cancer Institute, Boston Children's Hospital, Boston, Massachusetts
| | - John R Wingard
- Department of Medicine, University of Florida Health Cancer Center, Gainesville, Florida; Bone Marrow Transplant Program, Division of Hematology/Oncology, University of Florida College of Medicine, Florida
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Robert R Jenq
- Departments of Genomic Medicine and Stem Cell Transplantation Cellular Therapy, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Ami S Bhatt
- Department of Genetics and Division of Hematology, Department of Medicine, Stanford University, Stanford, California.
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57
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Shepard B, Trower C, Hendrickson S. Toxic Injury to the Gastrointestinal Tract After Ipilimumab Therapy for Advanced Melanoma. J Osteopath Med 2018; 118:40-44. [DOI: 10.7556/jaoa.2018.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Ipilimumab, cytotoxic T-lymphocyte-associated protein 4–blocking antibody, is known to precipitate tissue-specific immune-related adverse events. The second most common site for immune-related adverse events is the gastrointestinal tract, with toxic injury resulting in diarrhea, colitis, and enterocolitis. In the present case, a woman who received ipilimumab 2 weeks prior was found to have severe, diffuse corticosteroid-refractory gastrointestinal tract toxic injury affecting the stomach, small bowel, and colon.
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58
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Shallis RM, Terry CM, Lim SH. Changes in intestinal microbiota and their effects on allogeneic stem cell transplantation. Am J Hematol 2018; 93:122-128. [PMID: 28842931 DOI: 10.1002/ajh.24896] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/31/2017] [Accepted: 08/22/2017] [Indexed: 12/30/2022]
Abstract
The human intestinal microbiota is essential for microbial homeostasis, regulation of metabolism, and intestinal immune tolerance. Rapidly evolving understanding of the importance of the microbiota implicates changes in the composition and function of intestinal microbial communities in an assortment of systemic conditions. Complications following allogeneic stem cell transplant now join the ever-expanding list of pathologic states regulated by intestinal microbiota. Dysbiosis, or disruption of the normal ecology of this microbiome, has been directly implicated in the pathogenesis of entities such as Clostridium difficile infections, graft-versus-host disease (GVHD), and most recently disease relapse, all of which are major causes of morbidity and mortality in patients undergoing allogeneic stem cell transplant. In this review, we elucidate the key origins of microbiotic alterations and discuss how dysbiosis influences complications following allogeneic stem cell transplant. Our emerging understanding of the importance of a balanced and diverse intestinal microbiota is prompting investigation into the appropriate treatment of dysbiosis, reliable and early detection of such, and ultimately its prevention in patients to improve the outcome following allogeneic hematopoietic stem cell transplant.
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Affiliation(s)
- Rory M. Shallis
- Division of Hematology and Oncology; Rhode Island Hospital/Brown University Warren Alpert School of Medicine; Providence Rhode Island
| | - Christopher M. Terry
- Division of Hematology and Oncology; Rhode Island Hospital/Brown University Warren Alpert School of Medicine; Providence Rhode Island
| | - Seah H. Lim
- Division of Hematology and Oncology; Rhode Island Hospital/Brown University Warren Alpert School of Medicine; Providence Rhode Island
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59
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Reddy P, Ferrara JL. Graft-Versus-Host Disease and Graft-Versus-Leukemia Responses. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00108-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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60
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Sadowska-Klasa A, Piekarska A, Prejzner W, Bieniaszewska M, Hellmann A. Colonization with multidrug-resistant bacteria increases the risk of complications and a fatal outcome after allogeneic hematopoietic cell transplantation. Ann Hematol 2017; 97:509-517. [PMID: 29255911 PMCID: PMC5797223 DOI: 10.1007/s00277-017-3205-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/07/2017] [Indexed: 02/07/2023]
Abstract
Composition of the gut microbiota seems to influence early complications of allogeneic hematopoietic cell transplantation (HCT) such as bacterial infections and acute graft-versus-host disease (GVHD). In this study, we assessed the impact of colonization with multidrug-resistant bacteria (MDRB) prior to HCT and the use of antibiotics against anaerobic bacteria on the outcomes of HCT. We retrospectively analyzed the data of 120 patients who underwent HCT for hematologic disorders between 2012 and 2014. Fifty-one (42.5%) patients were colonized with MDRB and 39 (32.5%) had infections caused by MDRB. Prior colonization was significantly correlated with MDRB infections (P < 0.001), especially bacteremia (P = 0.038). A higher incidence of MDRB infections was observed in patients with acute (P = 0.014) or chronic (P = 0.002) GVHD and in patients aged > 40 years (P = 0.002). Colonization had a negative impact on overall survival (OS) after HCT (64 vs. 47% at 24 months; P = 0.034) and infection-associated mortality (P < 0.001). Use of metronidazole was correlated with an increased incidence of acute GVHD (P < 0.001) and lower OS (P = 0.002). Patients colonized with MDRB are more susceptible to life-threatening infections. Colonization with virulent flora is the most probable source of neutropenic infection; therefore, information about prior positive colonization should be crucial for the selection of empiric antibiotic therapy. The use of metronidazole, affecting the biodiversity of the intestinal microbiome, seems to have a significant impact on OS and acute GVHD.
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Affiliation(s)
- Alicja Sadowska-Klasa
- Department of Hematology and Transplantology, University Clinical Center, Medical University of Gdansk, Dębinki 7, 80-952, Gdańsk, Poland
| | - Agnieszka Piekarska
- Department of Hematology and Transplantology, University Clinical Center, Medical University of Gdansk, Dębinki 7, 80-952, Gdańsk, Poland.
| | - Witold Prejzner
- Department of Hematology and Transplantology, University Clinical Center, Medical University of Gdansk, Dębinki 7, 80-952, Gdańsk, Poland
| | - Maria Bieniaszewska
- Department of Hematology and Transplantology, University Clinical Center, Medical University of Gdansk, Dębinki 7, 80-952, Gdańsk, Poland
| | - Andrzej Hellmann
- Department of Hematology and Transplantology, University Clinical Center, Medical University of Gdansk, Dębinki 7, 80-952, Gdańsk, Poland
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61
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Empiric antibiotic use in allogeneic hematopoietic cell transplantation: should we avoid anaerobe coverage? Blood Adv 2017; 1:2325-2328. [PMID: 29296882 DOI: 10.1182/bloodadvances.2017005108] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 10/24/2017] [Indexed: 12/30/2022] Open
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62
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Zogas N, Karponi G, Iordanidis F, Malasidis S, Paraskevas V, Papadopoulou A, Scouras ZG, Anagnostopoulos A, Yannaki E. The ex vivo toll-like receptor 7 tolerance induction in donor lymphocytes prevents murine acute graft-versus-host disease. Cytotherapy 2017; 20:149-164. [PMID: 29150086 DOI: 10.1016/j.jcyt.2017.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 08/27/2017] [Accepted: 09/11/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND AIMS Acute graft-versus-host disease (aGVHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation, mediated by alloreactive donor T cells. Toll-like receptors (TLRs), a family of conserved pattern-recognition receptors (PRRs), represent key players in donors' T-cell activation during aGVHD; however, a regulatory, tolerogenic role for certain TLRs has been recognized in a different context. We investigated whether the ex vivo-induced TLR-2,-4,-7 tolerance in donor cells could prevent alloreactivity in a mismatched transplantation model. METHODS TLR-2,-4,-7 tolerance was induced in mouse splenocytes, after stimulation with low doses of corresponding ligands. Cellular and molecular changes of the TLR-tolerant splenocytes and purified T cells were assessed by immunophenotypic and gene expression analyses. Incidence of aGVHD was evaluated by the clinical score and survival as well as histopathology of target tissues. RESULTS Only the R848-induced TLR7 tolerance prevented aGVHD. The TLR7 ligand-induced tolerance lasted for a critical post-transplant period and was associated with distinct cellular and molecular signatures characterized by induction of regulatory T cells, reduced alloreactivity and balanced regulation of inflammatory signaling and innate immune responses. The TLR7-tolerant T cells preserved the immunological memory and generated in vitro virus-specific T cells upon antigen stimulation. The anti-aGVHD tolerization effect was direct and specific to TLR7 and required the receptor-ligand interaction; TLR7-/- T cells isolated from B6 TLR7-/- mice presented a distinct gene expression profile but failed to prevent aGVHD. DISCUSSION We propose an effective and clinically applicable ex vivo approach for aGVHD prevention through a transient and reversible immune reprogramming exerted by TLR7-tolerant donor lymphocytes.
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Affiliation(s)
- Nikolaos Zogas
- Gene and Cell Therapy Center, Hematology Department-BMT Unit, George Papanicolaou Hospital, Thessaloniki, Greece; Department of Genetics, Development and Molecular Biology, School of Biology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Garyfalia Karponi
- Gene and Cell Therapy Center, Hematology Department-BMT Unit, George Papanicolaou Hospital, Thessaloniki, Greece
| | - Fotios Iordanidis
- Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, United Kingdom
| | - Stylianos Malasidis
- Gene and Cell Therapy Center, Hematology Department-BMT Unit, George Papanicolaou Hospital, Thessaloniki, Greece
| | - Vasilios Paraskevas
- Gene and Cell Therapy Center, Hematology Department-BMT Unit, George Papanicolaou Hospital, Thessaloniki, Greece; Department of Genetics, Development and Molecular Biology, School of Biology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasia Papadopoulou
- Gene and Cell Therapy Center, Hematology Department-BMT Unit, George Papanicolaou Hospital, Thessaloniki, Greece
| | - Zaharias George Scouras
- Department of Genetics, Development and Molecular Biology, School of Biology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Achilles Anagnostopoulos
- Gene and Cell Therapy Center, Hematology Department-BMT Unit, George Papanicolaou Hospital, Thessaloniki, Greece
| | - Evangelia Yannaki
- Gene and Cell Therapy Center, Hematology Department-BMT Unit, George Papanicolaou Hospital, Thessaloniki, Greece; Department of Medicine, University of Washington, Seattle, Washington, USA.
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63
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Perkey E, Maillard I. New Insights into Graft-Versus-Host Disease and Graft Rejection. ANNUAL REVIEW OF PATHOLOGY-MECHANISMS OF DISEASE 2017; 13:219-245. [PMID: 29099650 DOI: 10.1146/annurev-pathol-020117-043720] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Allogeneic transplantation of foreign organs or tissues has lifesaving potential, but can lead to serious complications. After solid organ transplantation, immune-mediated rejection mandates the use of prolonged global immunosuppression and limits the life span of transplanted allografts. After bone marrow transplantation, donor-derived immune cells can trigger life-threatening graft-versus-host disease. T cells are central mediators of alloimmune complications and the target of most existing therapeutic interventions. We review recent progress in identifying multiple cell types in addition to T cells and new molecular pathways that regulate pathogenic alloreactivity. Key discoveries include the cellular subsets that function as potential sources of alloantigens, the cross talk of innate lymphoid cells with damaged epithelia and with the recipient microbiome, the impact of the alarmin interleukin-33 on alloreactivity, and the role of Notch ligands expressed by fibroblastic stromal cells in alloimmunity. While refining our understanding of transplantation immunobiology, these findings identify new therapeutic targets and new areas of investigation.
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Affiliation(s)
- Eric Perkey
- Life Sciences Institute, University of Michigan, Ann Arbor, Michigan 48109, USA;
| | - Ivan Maillard
- Life Sciences Institute, University of Michigan, Ann Arbor, Michigan 48109, USA; .,Department of Internal Medicine, Division of Hematology-Oncology, and Department of Cell and Developmental Biology, University of Michigan, Ann Arbor, Michigan 48109, USA.,Department of Medicine, Division of Hematology-Oncology, and Abramson Family Cancer Research Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA;
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64
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Role of the intestinal mucosa in acute gastrointestinal GVHD. Blood 2017; 128:2395-2402. [PMID: 27856471 DOI: 10.1182/blood-2016-06-716738] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/14/2016] [Indexed: 12/11/2022] Open
Abstract
Intestinal graft-versus-host disease (GVHD) remains a significant obstacle to the success of allogeneic hematopoietic cell transplantation. The intestinal mucosa comprises the inner lining of the intestinal tract and maintains close proximity with commensal microbes that reside within the intestinal lumen. Recent advances have significantly improved our understanding of the interactions between the intestinal mucosa and the enteric microbiota. Changes in host mucosal tissue and commensals posttransplant have been actively investigated, and provocative insights into mucosal immunity and the enteric microbiota are now being translated into clinical trials of novel approaches for preventing and treating acute GVHD. In this review, we summarize recent findings related to aspects of the intestinal mucosa during acute GVHD.
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65
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Integrated meta-omic analyses of the gastrointestinal tract microbiome in patients undergoing allogeneic hematopoietic stem cell transplantation. Transl Res 2017; 186:79-94.e1. [PMID: 28686852 DOI: 10.1016/j.trsl.2017.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 05/17/2017] [Accepted: 06/12/2017] [Indexed: 02/06/2023]
Abstract
In patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), treatment-induced changes to the gastrointestinal tract (GIT) microbiome have been linked to adverse outcomes, most notably graft-versus-host disease (GvHD). However, it is presently unknown whether this relationship is causal or consequential. Here, we performed an integrated meta-omic analysis to probe deeper into the GIT microbiome changes during allo-HSCT and its accompanying treatments. We used 16S and 18S rRNA gene amplicon sequencing to resolve archaea, bacteria, and eukaryotes within the GIT microbiomes of 16 patients undergoing allo-HSCT for the treatment of hematologic malignancies. These results revealed a major shift in the GIT microbiome after allo-HSCT including a marked reduction in bacterial diversity, accompanied by only limited changes in eukaryotes and archaea. An integrated analysis of metagenomic and metatranscriptomic data was performed on samples collected from a patient before and after allo-HSCT for acute myeloid leukemia. This patient developed severe GvHD, leading to death 9 months after allo-HSCT. In addition to drastically decreased bacterial diversity, the post-treatment microbiome showed a higher overall number and higher expression levels of antibiotic resistance genes (ARGs). One specific Escherichia coli strain causing a paravertebral abscess was linked to GIT dysbiosis, suggesting loss of intestinal barrier integrity. The apparent selection for bacteria expressing ARGs suggests that prophylactic antibiotic administration may adversely affect the overall treatment outcome. We therefore assert that such analyses including information about the selection of pathogenic bacteria expressing ARGs may assist clinicians in "personalizing" regimens for individual patients to improve overall outcomes.
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66
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Lee YK, Kang M, Choi EY. TLR/MyD88-mediated Innate Immunity in Intestinal Graft-versus-Host Disease. Immune Netw 2017; 17:144-151. [PMID: 28680375 PMCID: PMC5484644 DOI: 10.4110/in.2017.17.3.144] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/07/2017] [Accepted: 04/13/2017] [Indexed: 12/13/2022] Open
Abstract
Graft-versus-host disease (GHVD) is a severe complication after allogeneic hematopoietic stem cell transplantation. The degree of inflammation in the gastrointestinal tract, a major GVHD target organ, correlates with the disease severity. Intestinal inflammation is initiated by epithelial damage caused by pre-conditioning irradiation. In combination with damages caused by donor-derived T cells, such damage disrupts the epithelial barrier and exposes innate immune cells to pathogenic and commensal intestinal bacteria, which release ligands for Toll-like receptors (TLRs). Dysbiosis of intestinal microbiota and signaling through the TLR/myeloid differentiation primary response gene 88 (MyD88) pathways contribute to the development of intestinal GVHD. Understanding the changes in the microbial flora and the roles of TLR signaling in intestinal GVHD will facilitate the development of preventative and therapeutic strategies.
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Affiliation(s)
- Young-Kwan Lee
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Myungsoo Kang
- BioMembrane Plasticity Research Center (MPRC), Seoul National University College of Medicine, Seoul 03080, Korea
| | - Eun Young Choi
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul 03080, Korea.,BioMembrane Plasticity Research Center (MPRC), Seoul National University College of Medicine, Seoul 03080, Korea
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67
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Tvedt THA, Ersvaer E, Tveita AA, Bruserud Ø. Interleukin-6 in Allogeneic Stem Cell Transplantation: Its Possible Importance for Immunoregulation and As a Therapeutic Target. Front Immunol 2017. [PMID: 28642760 PMCID: PMC5462914 DOI: 10.3389/fimmu.2017.00667] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Allogeneic stem cell transplantation is associated with a high risk of treatment-related mortality mainly caused by infections and graft-versus-host disease (GVHD). GVHD is characterized by severe immune dysregulation and impaired regeneration of different tissues, i.e., epithelial barriers and the liver. The balance between pro- and anti-inflammatory cytokine influences the risk of GVHD. Interleukin-6 (IL-6) is a cytokine that previously has been associated with pro-inflammatory effects. However, more recent evidence from various autoimmune diseases (e.g., inflammatory bowel disease, rheumatoid arthritis) has shown that the IL-6 activity is more complex with important effects also on tissue homeostasis, regeneration, and metabolism. This review summarizes the current understanding of how pro-inflammatory IL-6 effects exerted during the peritransplant period shapes T-cell polarization with enhancement of Th17 differentiation and suppression of regulatory T cells, and in addition we also review and discuss the results from trials exploring non-selective IL-6 inhibition in prophylaxis and treatment of GVHD. Emerging evidence suggests that the molecular strategy for targeting of IL-6-initiated intracellular signaling is important for the effect on GVHD. It will therefore be important to further characterize the role of IL-6 in the pathogenesis of GVHD to clarify whether combined IL-6 inhibition of both trans- (i.e., binding of the soluble IL-6/IL-6 receptor complex to cell surface gp130) and cis-signaling (i.e., IL-6 ligation of the IL-6 receptor/gp130 complex) or selective inhibition of trans-signaling should be tried in the prophylaxis and/or treatment of GVHD in allotransplant patients.
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Affiliation(s)
- Tor Henrik Anderson Tvedt
- Department of Clinical Science, Section for Hematology, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Elisabeth Ersvaer
- Institute of Biomedical Laboratory Sciences and Chemical Engineering, Western Norway University of Applied Sciences (HVL), Bergen, Norway
| | - Anders Aune Tveita
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Øystein Bruserud
- Department of Clinical Science, Section for Hematology, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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68
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Dickinson AM, Norden J, Li S, Hromadnikova I, Schmid C, Schmetzer H, Jochem-Kolb H. Graft-versus-Leukemia Effect Following Hematopoietic Stem Cell Transplantation for Leukemia. Front Immunol 2017. [PMID: 28638379 PMCID: PMC5461268 DOI: 10.3389/fimmu.2017.00496] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The success of hematopoietic stem cell transplantation (HSCT) lies with the ability of the engrafting immune system to remove residual leukemia cells via a graft-versus-leukemia effect (GvL), caused either spontaneously post-HSCT or via donor lymphocyte infusion. GvL effects can also be initiated by allogenic mismatched natural killer cells, antigen-specific T cells, and activated dendritic cells of leukemic origin. The history and further application of this GvL effect and the main mechanisms will be discussed and reviewed in this chapter.
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Affiliation(s)
- Anne M Dickinson
- Haematological Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Jean Norden
- Haematological Sciences, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Shuang Li
- Third Faculty of Medicine, Department of Molecular Biology and Cell Pathology, Charles University, Prague, Czechia
| | - Ilona Hromadnikova
- Third Faculty of Medicine, Department of Molecular Biology and Cell Pathology, Charles University, Prague, Czechia
| | - Christoph Schmid
- Department for Hematopoietic Cell Transplantation, University Hospital Augsburg, Munich, Germany
| | - Helga Schmetzer
- Department for Hematopoietic Cell Transplantation, Internal Medicine III, Hospital of the University of Munich, Munich, Germany
| | - Hans Jochem-Kolb
- Department of Hematology-Oncology Immunology Infectious Diseases, Klinikum München-Schwabing, Munich, Germany
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69
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Ferrara JL, Smith CM, Sheets J, Reddy P, Serody JS. Altered homeostatic regulation of innate and adaptive immunity in lower gastrointestinal tract GVHD pathogenesis. J Clin Invest 2017; 127:2441-2451. [PMID: 28581444 DOI: 10.1172/jci90592] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Lower gastrointestinal (GI) tract graft-versus-host disease (GVHD) is the predominant cause of morbidity and mortality from GVHD after allogeneic stem cell transplantation. Recent data indicate that lower GI tract GVHD is a complicated process mediated by donor/host antigenic disparities. This process is exacerbated by significant changes to the microbiome, and innate and adaptive immune responses that are critical to the induction of disease, persistence of inflammation, and a lack of response to therapy. Here, we discuss new insights into the biology of lower GI tract GVHD and focus on intrinsic pathways and regulatory mechanisms crucial to normal intestinal function. We then describe multiple instances in which these homeostatic mechanisms are altered by donor T cells or conditioning therapy, resulting in exacerbation of GVHD. We also discuss data suggesting that some of these mechanisms produce biomarkers that could be informative as to the severity of GVHD and its response to therapy. Finally, novel therapies that might restore homeostasis in the GI tract during GVHD are highlighted.
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Affiliation(s)
- James Lm Ferrara
- Departments of Medicine, Pediatrics, and Academic Informatics and Technology, Icahn School of Medicine at Mount Sinai and Tisch Cancer Institute, New York, New York, USA
| | - Christopher M Smith
- Departments of Medicine, Pediatrics, and Academic Informatics and Technology, Icahn School of Medicine at Mount Sinai and Tisch Cancer Institute, New York, New York, USA
| | - Julia Sheets
- University of North Carolina Hospital, Chapel Hill, North Carolina, USA
| | - Pavan Reddy
- Department of Medicine and University of Michigan Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan S Serody
- Department of Medicine and UNC Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
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70
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El-Jurdi N, de Lima M, Lazarus H, Ghannoum MA. Microbiome: Its Impact Is Being Revealed! CURRENT CLINICAL MICROBIOLOGY REPORTS 2017. [DOI: 10.1007/s40588-017-0063-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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71
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Slingerland AE, Schwabkey Z, Wiesnoski DH, Jenq RR. Clinical Evidence for the Microbiome in Inflammatory Diseases. Front Immunol 2017; 8:400. [PMID: 28446909 PMCID: PMC5388779 DOI: 10.3389/fimmu.2017.00400] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/21/2017] [Indexed: 12/11/2022] Open
Abstract
Clinical evidence is accumulating for a role of the microbiome in contributing to or modulating severity of inflammatory diseases. These studies can be organized by various organ systems involved, as well as type of study approach utilized, whether investigators compared the microbiome of cases versus controls, followed patients longitudinally, or intervened with antibiotics, prebiotics, or bacterial introduction. In this review, we summarize the clinical evidence supporting the microbiome as an important mechanism in the onset and maintenance of inflammation.
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Affiliation(s)
- Ann E Slingerland
- Immunology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zaker Schwabkey
- Department of Genomic Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Diana H Wiesnoski
- Department of Genomic Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert R Jenq
- Department of Genomic Medicine, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Stem Cell Transplantation Cellular Therapy, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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72
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Staffas A, Burgos da Silva M, van den Brink MRM. The intestinal microbiota in allogeneic hematopoietic cell transplant and graft-versus-host disease. Blood 2017; 129:927-933. [PMID: 27940475 PMCID: PMC5324712 DOI: 10.1182/blood-2016-09-691394] [Citation(s) in RCA: 137] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 12/05/2016] [Indexed: 12/14/2022] Open
Abstract
Hematopoietic cell transplantation (HCT) is a critical treatment of patients with high-risk hematopoietic malignancies, hematological deficiencies, and other immune diseases. In allogeneic HCT (allo-HCT), donor-derived T cells recognize host tissues as foreign, causing graft-versus-host disease (GVHD) which is a main contributor to morbidity and mortality. The intestine is one of the organs most severely affected by GVHD and research has recently highlighted the importance of bacteria, particularly the gut microbiota, in HCT outcome and in GVHD development. Loss of intestinal bacterial diversity is common during the course of HCT and is associated with GVHD development and treatment with broad-spectrum antibiotics. Loss of intestinal diversity and outgrowth of opportunistic pathogens belonging to the phylum Proteobacteria and Enterococcus genus have also been linked to increased treatment-related mortality including GVHD, infections, and organ failure after allo-HCT. Experimental studies in allo-HCT animal models have shown some promising results for prebiotic and probiotic strategies as prophylaxis or treatment of GVHD. Continuous research will be important to define the relation of cause and effect for these associations between microbiota features and HCT outcomes. Importantly, studies focused on geographic and cultural differences in intestinal microbiota are necessary to define applicability of new strategies targeting the intestinal microbiota.
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Affiliation(s)
- Anna Staffas
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marina Burgos da Silva
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marcel R M van den Brink
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine and
- Department of Immunology, Weill Medical College of Cornell University, New York, NY; and
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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73
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Khoruts A, Hippen KL, Lemire AM, Holtan SG, Knights D, Young JAH. Toward revision of antimicrobial therapies in hematopoietic stem cell transplantation: target the pathogens, but protect the indigenous microbiota. Transl Res 2017; 179:116-125. [PMID: 27513211 PMCID: PMC5555748 DOI: 10.1016/j.trsl.2016.07.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 07/12/2016] [Accepted: 07/15/2016] [Indexed: 12/13/2022]
Abstract
Host microbiota plays important roles in providing colonization resistance to pathogens and instructing development and function of the immune system. Antibiotic treatments intended to target pathogens further weaken the host defenses and may paradoxically increase the risk of systemic infections. This consequence is especially problematic in patients undergoing hematopoietic stem cell transplantation, where the mucosal defenses are already weakened by the conditioning regimens. This review discusses the roles that indigenous microbiota plays in protecting the host and maintaining immune homeostasis. In addition, we highlight possible strategies that are being developed to allow targeted antimicrobial therapy against pathogens, while minimizing the harm to indigenous microbiota.
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Affiliation(s)
- Alexander Khoruts
- Division of Gastroenterology, Department of Medicine, Center for Immunology and Biotechnology Institute, University of Minnesota, Minneapolis, Minn.
| | - Keli L Hippen
- Division of Hematology/Oncology and Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
| | - Amanda M Lemire
- Division of Hematology/Oncology and Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
| | - Shernan G Holtan
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, Minneapolis, Minn
| | - Dan Knights
- Department of Computer Science and Engineering, Biotechnology Institute, University of Minnesota, Minneapolis, Minn
| | - Jo-Anne H Young
- Division of Infectious Diseases, Department of Medicine, University of Minnesota, Minneapolis, Minn
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74
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Raghunathan VM, Sheng I, Lim SH. Intestinal dysbiosis and allogeneic hematopoietic progenitor cell transplantation. J Transl Med 2016; 14:335. [PMID: 27912759 PMCID: PMC5135767 DOI: 10.1186/s12967-016-1094-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/23/2016] [Indexed: 02/08/2023] Open
Abstract
The intestinal microbiota is a diverse and dynamic ecosystem that is increasingly understood to play a vital role in human health. Hematopoietic stem cell transplant recipients undergo prolonged exposure to antimicrobials, chemotherapeutic agents, and immunosuppressants, resulting in profound shifts in the gut microbiome. A growing body of research has revealed the ways in which these microbiologic shifts shape immune modulation, affecting susceptibility to infections and graft-versus-host disease, the two major post-transplant complications in this population. As transplant medicine becomes increasingly personalized, the potential for microbiome-modulating treatments holds immense potential. Strategies to preserve the intestinal microbiota, including targeted antibiotics, prebiotics and probiotics, and fecal microbiota transplant could mitigate some of the microbiologic shifts in stem cell transplant recipients, and reduce the incidence of peri-transplant morbidity and mortality.
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Affiliation(s)
- Vikram M Raghunathan
- Division of Hematology and Oncology, Department of Medicine, Rhode Island Hospital, Room 140 APC Building, 593 Eddy Street, Providence, RI, 02903, USA.,Brown University Warren Alpert School of Medicine, Providence, USA
| | - Iris Sheng
- Division of Hematology and Oncology, Department of Medicine, Rhode Island Hospital, Room 140 APC Building, 593 Eddy Street, Providence, RI, 02903, USA.,Brown University Warren Alpert School of Medicine, Providence, USA
| | - Seah H Lim
- Division of Hematology and Oncology, Department of Medicine, Rhode Island Hospital, Room 140 APC Building, 593 Eddy Street, Providence, RI, 02903, USA. .,Brown University Warren Alpert School of Medicine, Providence, USA.
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75
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Peled JU, Hanash AM, Jenq RR. Role of the intestinal mucosa in acute gastrointestinal GVHD. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:119-127. [PMID: 27913470 PMCID: PMC5575743 DOI: 10.1182/asheducation-2016.1.119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Intestinal graft-versus-host disease (GVHD) remains a significant obstacle to the success of allogeneic hematopoietic cell transplantation. The intestinal mucosa comprises the inner lining of the intestinal tract and maintains close proximity with commensal microbes that reside within the intestinal lumen. Recent advances have significantly improved our understanding of the interactions between the intestinal mucosa and the enteric microbiota. Changes in host mucosal tissue and commensals posttransplant have been actively investigated, and provocative insights into mucosal immunity and the enteric microbiota are now being translated into clinical trials of novel approaches for preventing and treating acute GVHD. In this review, we summarize recent findings related to aspects of the intestinal mucosa during acute GVHD.
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Affiliation(s)
- Jonathan U Peled
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; and
- Weill Cornell Medical College, New York, NY
| | - Alan M Hanash
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Robert R Jenq
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; and
- Weill Cornell Medical College, New York, NY
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76
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Taur Y. Intestinal microbiome changes and stem cell transplantation: Lessons learned. Virulence 2016; 7:930-938. [PMID: 27805463 PMCID: PMC5160401 DOI: 10.1080/21505594.2016.1250982] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 02/08/2023] Open
Abstract
Studies of the microbiome in the setting of haematopoietic stem cell transplantation (SCT) have shown evidence that intestinal microbes appear to play a particularly important role in determining the outcome of treatment, impacting complications such as infection or graft-versus-host disease. Past studies may vary in terms of the level at which the microbiome is examined, leading to different but overlapping systems of taxonomy or nomenclature, which may be difficult for non-specialists to understand. This article will review the current body of work examining the clinical impact of the microbiome on SCT, and will provide a basic framework for the bacterial phylogenetic structure upon which the results of these studies rest. With this framework it can be shown that recurring patterns do emerge in prior studies identifying the microbes that confer benefit in this population.
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Affiliation(s)
- Ying Taur
- Medicine, Infectious Diseases Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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77
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Modulation of Immunoregulatory Properties of Mesenchymal Stromal Cells by Toll-Like Receptors: Potential Applications on GVHD. Stem Cells Int 2016; 2016:9434250. [PMID: 27738438 PMCID: PMC5050362 DOI: 10.1155/2016/9434250] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/22/2016] [Indexed: 12/25/2022] Open
Abstract
In the last decade, the immunomodulatory properties of mesenchymal stromal cells (MSCs) have attracted a lot of attention, due to their potential applicability in the treatment of graft-versus-host disease (GVHD), a condition frequently associated with opportunistic infections. The present review addresses how Pathogen-Associated Molecular Patterns (PAMPS) modulate the immunosuppressive phenotype of human MSCs by signaling through Toll-like receptors (TLRs). Overall, we observed that regardless of the source tissue, human MSCs express TLR2, TLR3, TLR4, and TLR9. Stimulation of distinct TLRs on MSCs elicits distinct inflammatory signaling pathways, differentially influencing the expression of inflammatory factors and the ability of MSCs to suppress the proliferation of immune system cells. The capacity to enhance the immunosuppressive phenotype of MSCs through TLRs stimulation might be properly elucidated in order to improve the MSC-based immunotherapy against GVHD.
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78
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Cooke KR, Olkiewicz K, Erickson N, Ferrara JL. The role of endotoxin and the innate immune response in the pathophysiology of acute graft versus host disease. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/09680519020080061301] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Allogeneic stem cell transplantation (SCT) is an important therapy for a number of malignant diseases, and acute graft versus host disease (GVHD) and leukemic relapse remain the two major obstacles to successful outcomes of this treatment strategy. The therapeutic potential of allogeneic SCT relies on the graft versus leukemia (GVL) effect, during which donor T lymphocytes eradicate residual malignant cells via immunological mechanisms. Unfortunately, beneficial GVL effects are closely associated with the toxicity of GVHD. The pathophysiology of GVHD is complex and fundamentally depends upon aspects of adaptive immunity and interactions between donor T cells and foreign host tissue antigens. Recent work has revealed that components of the innate immune response and the secretion of inflammatory cytokine effectors are also important. In this context, experimental studies have demonstrated that loss of gastrointestinal (GI) tract integrity plays a major role in the amplification of systemic GVHD. Specifically, translocation of endotoxin across a damaged GI tract and into the circulation promotes local and systemic cytokine release. This effect perpetuates further gut mucosal injury and endotoxin leak, thus establishing a positive feedback loop for progressive target organ injury and systemic inflammation. Data obtained using murine SCT models have shown that disruption of the cellular activating effects of lipopolysaccharide (LPS) significantly reduces cytokine secretion and GVHD severity without altering T-cell responses to host antigens. These findings support a critical role for LPS in the early inflammatory events responsible for GVHD and suggest that strategies which target the innate immune response and LPS receptor-ligand interactions may help prevent GVHD while preserving donor T-cell responses and GVL activity.
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Affiliation(s)
- Kenneth R. Cooke
- Department of Pediatrics, University of Michigan Cancer Center, Ann Arbor, Michigan, USA,
| | - Krystyna Olkiewicz
- Department of Pediatrics, University of Michigan Cancer Center, Ann Arbor, Michigan, USA
| | - Nicole Erickson
- Department of Pediatrics, University of Michigan Cancer Center, Ann Arbor, Michigan, USA
| | - James L.M. Ferrara
- Department of Pediatrics, University of Michigan Cancer Center, Ann Arbor, Michigan, USA, Department of Internal Medicine, Division of Hematology/Oncology, Blood and Marrow Transplantation Program, University of Michigan Cancer Center, Ann Arbor, Michigan, USA
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79
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Antibiotic-mediated modification of the intestinal microbiome in allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2016; 52:183-190. [PMID: 27526283 DOI: 10.1038/bmt.2016.206] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/08/2016] [Accepted: 05/09/2016] [Indexed: 12/15/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is curative for many patients with severe benign and malignant hematologic disorders. The success of allogeneic HSCT is limited by the development of transplant-related complications such as acute graft-versus-host disease (GvHD). Early pre-clinical studies suggested that intestinal microflora contribute to the pathogenesis of acute GvHD, and that growth suppression or eradication of intestinal bacteria prevented the development of acute GvHD even in MHC-mismatched transplants. These observations led to the practice of gut decontamination (GD) with oral non-absorbable antibiotics in patients undergoing allogeneic HSCT as a method of acute GvHD prophylaxis. Microbiome studies in the modern sequencing era are beginning to challenge the benefit of this practice. In this review, we provide a historical perspective on the practice of GD and highlight findings from the limited number of clinical trials evaluating the use of GD for acute GvHD prevention in allogeneic HSCT patients. In addition, we examine the role of the gut microbiota in allogeneic HSCT in the context of recent studies linking the microflora to regulation of intestinal immune homeostasis. We discuss the implications of these findings for future strategies to reduce acute GvHD risk by selective manipulation of the microbiota.
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80
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Tu S, Zhong D, Xie W, Huang W, Jiang Y, Li Y. Role of Toll-Like Receptor Signaling in the Pathogenesis of Graft-versus-Host Diseases. Int J Mol Sci 2016; 17:E1288. [PMID: 27529218 PMCID: PMC5000685 DOI: 10.3390/ijms17081288] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 07/12/2016] [Accepted: 08/03/2016] [Indexed: 12/20/2022] Open
Abstract
Graft-versus-host disease (GVHD) and infection are major complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and the leading causes of morbidity and mortality in HSCT patients. Recent work has demonstrated that the two complications are interdependent. GVHD occurs when allo-reactive donor T lymphocytes are activated by major histocompatibility antigens or minor histocompatibility antigens on host antigen-presenting cells (APCs), with the eventual attack of recipient tissues or organs. Activation of APCs is important for the priming of GVHD and is mediated by innate immune signaling pathways. Current evidence indicates that intestinal microbes and innate pattern-recognition receptors (PRRs) on host APCs, including both Toll-like receptors (TLRs) and nucleotide oligomerization domain (NOD)-like receptors (NLRs), are involved in the pathogenesis of GVHD. Patients undergoing chemotherapy and/or total body irradiation before allo-HSCT are susceptible to aggravated gastrointestinal epithelial cell damage and the subsequent translocation of bacterial components, followed by the release of endogenous dangerous molecules, termed pathogen-associated molecular patterns (PAMPs), which then activate the PRRs on host APCs to trigger local or systemic inflammatory responses that modulate T cell allo-reactivity against host tissues, which is equivalent to GVHD. In other words, infection can, to some extent, accelerate the progression of GVHD. Therefore, the intestinal flora's PAMPs can interact with TLRs to activate and mature APCs, subsequently activate donor T cells with the release of pro-inflammatory cytokines, and eventually, induce GVHD. In the present article, we summarize the current perspectives on the understanding of different TLR signaling pathways and their involvement in the occurrence of GVHD.
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Affiliation(s)
- Sanfang Tu
- Department of Haematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| | - Danli Zhong
- Second Clinical Medical College, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| | - Weixin Xie
- Second Clinical Medical College, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| | - Wenfa Huang
- Second Clinical Medical College, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| | - Yangyang Jiang
- Department of Haematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
| | - Yuhua Li
- Department of Haematology, Zhujiang Hospital, Southern Medical University, Guangzhou 510282, China.
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81
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Koldehoff M, Ross SR, Dührsen U, Beelen DW, Elmaagacli AH. Early CMV-replication after allogeneic stem cell transplantation is associated with a reduced relapse risk in lymphoma. Leuk Lymphoma 2016; 58:822-833. [PMID: 27687578 DOI: 10.1080/10428194.2016.1217524] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A preventive effect of early human cytomegalovirus (HCMV) replication was evaluated in 136 non-Hodgkin lymphoma (NHL) patients with mature B-cell NHLs (n = 94), and mature T- and NK-cell NHLs (n = 42) after allogeneic stem cell transplantation (alloSCT). Most study-patients (85%) had received at least 2 cycles of chemotherapy and 60% had also received an autograft prior to alloSCT. First detection of CMV-replication by HCMV antigenemia/viremia was found at a median of day +33 after alloSCT. The cumulative incidence of relapse at 5 years after alloSCT was 38% (95% confidence interval [95%CI]: 26-49) in 82 patients without compared to 22% (95%CI: 8-37) in 54 patients with HCMV antigenemia/viremia (p = .013). A decreased relapse risk of HCMV replication was confirmed by multivariate analysis for HCMV antigenemia/viremia (Hazard ratio [HR]: 0.29, 95%CI: 0.11-0.76, p < .014). This report demonstrated a possible improvement of relapse incidence after replicative HCMV infection in patients with NHL after alloSCT.
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Affiliation(s)
- Michael Koldehoff
- a Department of Bone Marrow Transplantation , West German Cancer Center, University Hospital Essen, University of Duisburg-Essen , Essen , Germany
| | - Stefan R Ross
- b Institute of Virology, University Hospital Essen, University of Duisburg-Essen , Essen , Germany
| | - Ulrich Dührsen
- c Department of Hematology , West German Cancer Center, University Hospital Essen, University of Duisburg-Essen , Essen , Germany
| | - Dietrich W Beelen
- a Department of Bone Marrow Transplantation , West German Cancer Center, University Hospital Essen, University of Duisburg-Essen , Essen , Germany
| | - Ahmet H Elmaagacli
- a Department of Bone Marrow Transplantation , West German Cancer Center, University Hospital Essen, University of Duisburg-Essen , Essen , Germany.,d Department of Oncology and Hematology , HELIOS Schwerin , Schwerin , Germany
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82
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Jenq RR, van den Brink MRM. Antibiotic prophylaxis in allogeneic stem cell transplantation-what is the correct choice? Bone Marrow Transplant 2016; 51:1071-2. [PMID: 27214076 DOI: 10.1038/bmt.2016.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/26/2016] [Indexed: 11/09/2022]
Affiliation(s)
- R R Jenq
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - M R M van den Brink
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA.,Department of Immunology, Sloan Kettering Institute for Cancer Research, New York, NY, USA
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83
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Shono Y, Docampo MD, Peled JU, Perobelli SM, Velardi E, Tsai JJ, Slingerland AE, Smith OM, Young LF, Gupta J, Lieberman SR, Jay HV, Ahr KF, Rodriguez KAP, Xu K, Calarfiore M, Poeck H, Caballero S, Devlin SM, Rapaport F, Dudakov JA, Hanash AM, Gyurkocza B, Murphy GF, Gomes C, Liu C, Moss EL, Falconer SB, Bhatt AS, Taur Y, Pamer EG, van den Brink MR, Jenq RR. Increased GVHD-related mortality with broad-spectrum antibiotic use after allogeneic hematopoietic stem cell transplantation in human patients and mice. Sci Transl Med 2016; 8:339ra71. [PMID: 27194729 PMCID: PMC4991773 DOI: 10.1126/scitranslmed.aaf2311] [Citation(s) in RCA: 375] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/04/2016] [Indexed: 12/13/2022]
Abstract
Intestinal bacteria may modulate the risk of infection and graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Allo-HSCT recipients often develop neutropenic fever, which is treated with antibiotics that may target anaerobic bacteria in the gut. We retrospectively examined 857 allo-HSCT recipients and found that treatment of neutropenic fever with imipenem-cilastatin and piperacillin-tazobactam antibiotics was associated with increased GVHD-related mortality at 5 years (21.5% for imipenem-cilastatin-treated patients versus 13.1% for untreated patients, P = 0.025; 19.8% for piperacillin-tazobactam-treated patients versus 11.9% for untreated patients, P = 0.007). However, two other antibiotics also used to treat neutropenic fever, aztreonam and cefepime, were not associated with GVHD-related mortality (P = 0.78 and P = 0.98, respectively). Analysis of stool specimens from allo-HSCT recipients showed that piperacillin-tazobactam administration was associated with perturbation of gut microbial composition. Studies in mice demonstrated aggravated GVHD mortality with imipenem-cilastatin or piperacillin-tazobactam compared to aztreonam (P < 0.01 and P < 0.05, respectively). We found pathological evidence for increased GVHD in the colon of imipenem-cilastatin-treated mice (P < 0.05), but no difference in the concentration of short-chain fatty acids or numbers of regulatory T cells. Notably, imipenem-cilastatin treatment of mice with GVHD led to loss of the protective mucus lining of the colon (P < 0.01) and the compromising of intestinal barrier function (P < 0.05). Sequencing of mouse stool specimens showed an increase in Akkermansia muciniphila (P < 0.001), a commensal bacterium with mucus-degrading capabilities, raising the possibility that mucus degradation may contribute to murine GVHD. We demonstrate an underappreciated risk for the treatment of allo-HSCT recipients with antibiotics that may exacerbate GVHD in the colon.
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Affiliation(s)
- Yusuke Shono
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa D. Docampo
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan U. Peled
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Suelen M. Perobelli
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Enrico Velardi
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy
| | - Jennifer J. Tsai
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann E. Slingerland
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Odette M. Smith
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lauren F. Young
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jyotsna Gupta
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sophia R. Lieberman
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hillary V. Jay
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katya F. Ahr
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kori A. Porosnicu Rodriguez
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ke Xu
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marco Calarfiore
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hendrik Poeck
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Silvia Caballero
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M. Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Franck Rapaport
- Human Oncology & Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jarrod A. Dudakov
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Program in Immunology, Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Alan M. Hanash
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Boglarka Gyurkocza
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - George F. Murphy
- Program in Dermatopathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Camilla Gomes
- Program in Dermatopathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chen Liu
- Departments of Pathology and Laboratory Medicine, New Jersey Medical School and Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
| | - Eli L. Moss
- Department of Medicine and Genetics, Stanford University, Stanford, California
| | - Shannon B. Falconer
- Department of Medicine and Genetics, Stanford University, Stanford, California
| | - Ami S. Bhatt
- Department of Medicine and Genetics, Stanford University, Stanford, California
| | - Ying Taur
- Weill Medical College of Cornell University, New York, New York
- Infectious Diseases Service, Lucille Castori Center for Microbes, Inflammation & Cancer, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric G. Pamer
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
- Infectious Diseases Service, Lucille Castori Center for Microbes, Inflammation & Cancer, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcel R.M. van den Brink
- Department of Immunology, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert R. Jenq
- Weill Medical College of Cornell University, New York, New York
- Adult BMT Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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84
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Servais S, Beguin Y, Delens L, Ehx G, Fransolet G, Hannon M, Willems E, Humblet-Baron S, Belle L, Baron F. Novel approaches for preventing acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Expert Opin Investig Drugs 2016; 25:957-72. [PMID: 27110922 DOI: 10.1080/13543784.2016.1182498] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Allogeneic hematopoietic stem cell transplantation (alloHSCT) offers potential curative treatment for a wide range of malignant and nonmalignant hematological disorders. However, its success may be limited by post-transplant acute graft-versus-host disease (aGVHD), a systemic syndrome in which donor's immune cells attack healthy tissues in the immunocompromised host. aGVHD is one of the main causes of morbidity and mortality after alloHSCT. Despite standard GVHD prophylaxis regimens, aGVHD still develops in approximately 40-60% of alloHSCT recipients. AREAS COVERED In this review, after a brief summary of current knowledge on the pathogenesis of aGVHD, the authors review the current combination of a calcineurin inhibitor with an antimetabolite with or without added anti-thymocyte globulin (ATG) and emerging strategies for GVHD prevention. EXPERT OPINION A new understanding of the involvement of cytokines, intracellular signaling pathways, epigenetics and immunoregulatory cells in GVHD pathogenesis will lead to new standards for aGVHD prophylaxis allowing better prevention of severe aGVHD without affecting graft-versus-tumor effects.
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Affiliation(s)
- Sophie Servais
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium.,b GIGA I3 , University of Liège , Liège , Belgium
| | - Yves Beguin
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium.,b GIGA I3 , University of Liège , Liège , Belgium
| | - Loic Delens
- b GIGA I3 , University of Liège , Liège , Belgium
| | - Grégory Ehx
- b GIGA I3 , University of Liège , Liège , Belgium
| | | | | | - Evelyne Willems
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium
| | - Stéphanie Humblet-Baron
- c Translational Immunology Laboratory , VIB , Leuven , Belgium.,d Department of Microbiology and Immunology , KUL-University of Leuven , Leuven , Belgium
| | | | - Frédéric Baron
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium.,b GIGA I3 , University of Liège , Liège , Belgium
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85
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Alloantigen presentation and graft-versus-host disease: fuel for the fire. Blood 2016; 127:2963-70. [PMID: 27030390 DOI: 10.1182/blood-2016-02-697250] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 03/05/2016] [Indexed: 12/16/2022] Open
Abstract
Allogeneic stem cell transplantation (SCT) is a unique procedure, primarily in patients with hematopoietic malignancies, involving chemoradiotherapy followed by the introduction of donor hematopoietic and immune cells into an inflamed and lymphopenic environment. Interruption of the process by which recipient alloantigen is presented to donor T cells to generate graft-versus-host disease (GVHD) represents an attractive therapeutic strategy to prevent morbidity and mortality after SCT and has been increasingly studied in the last 15 years. However, the immune activation resulting in GVHD has no physiological equivalent in nature; alloantigen is ubiquitous, persists indefinitely, and can be presented by multiple cell types at numerous sites, often on incompatible major histocompatibility complex, and occurs in the context of intense inflammation early after SCT. The recognition that alloantigen presentation is also critical to the development of immunological tolerance via both deletional and regulatory mechanisms further adds to this complexity. Finally, GVHD itself appears capable of inhibiting the presentation of microbiological antigens by donor dendritic cells late after SCT that is mandatory for the establishment of effective pathogen-specific immunity. Here, we review our current understanding of alloantigen, its presentation by various antigen-presenting cells, subsequent recognition by donor T cells, and the potential of therapeutic strategies interrupting this disease-initiating process to modify transplant outcome.
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86
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Peled JU, Jenq RR, Holler E, van den Brink MRM. Role of gut flora after bone marrow transplantation. Nat Microbiol 2016; 1:16036. [PMID: 27572448 PMCID: PMC5027134 DOI: 10.1038/nmicrobiol.2016.36] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jonathan U. Peled
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert R. Jenq
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University Medical Center, Regensburg, Germany
| | - Marcel R. M. van den Brink
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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87
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Weber D, Oefner PJ, Dettmer K, Hiergeist A, Koestler J, Gessner A, Weber M, Stämmler F, Hahn J, Wolff D, Herr W, Holler E. Rifaximin preserves intestinal microbiota balance in patients undergoing allogeneic stem cell transplantation. Bone Marrow Transplant 2016; 51:1087-92. [PMID: 26999466 DOI: 10.1038/bmt.2016.66] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/24/2016] [Accepted: 02/09/2016] [Indexed: 12/19/2022]
Abstract
Intestinal dysbiosis has been associated with acute gastrointestinal GvHD and poor outcome following allogeneic stem cell transplantation (ASCT). To assess the effect of a switch in 2012 from ciprofloxacin/metronidazole to rifaximin for gut decontamination on intestinal microbiota composition and ASCT outcome, we retrospectively analyzed 394 patients receiving ASCT from September 2008 through June 2015. In 131 and 90 patients, respectively, urinary 3-indoxyl sulfate levels and intestinal enterococcal load were measured before conditioning and weekly within the first 28 days after ASCT. The use of rifaximin correlated with lower enterococcal positivity (6.9 vs 21.9%, P=0.05) and higher urinary 3-indoxyl sulfate concentrations (10.5 vs 4.6 μmoL/mmoL crea, P<0.001) after ASCT. Patients on rifaximin showed lower 1-year transplant-related mortality (P=0.04) and higher overall survival (P=0.008). Treatment of infectious complications with systemic antibiotics did not abrogate the beneficial effects of rifaximin on intestinal microbiota composition in the early course of ASCT and outcome. The data underscore the importance of maintaining a diverse population of symbiotic and mutualistic bacteria in the gut on ASCT outcome.
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Affiliation(s)
- D Weber
- Department of Hematology and Oncology, Internal Medicine III, University Medical Center, Regensburg, Germany
| | - P J Oefner
- Chair and Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - K Dettmer
- Chair and Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - A Hiergeist
- Institute of Clinical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - J Koestler
- Institute of Clinical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - A Gessner
- Institute of Clinical Microbiology and Hygiene, University of Regensburg, Regensburg, Germany
| | - M Weber
- Department of Orthopedic Surgery, University Medical Center, Regensburg, Germany
| | - F Stämmler
- Chair of Statistical Bioinformatics, Institute of Functional Genomics, University of Regensburg, Regensburg, Germany
| | - J Hahn
- Department of Hematology and Oncology, Internal Medicine III, University Medical Center, Regensburg, Germany
| | - D Wolff
- Department of Hematology and Oncology, Internal Medicine III, University Medical Center, Regensburg, Germany
| | - W Herr
- Department of Hematology and Oncology, Internal Medicine III, University Medical Center, Regensburg, Germany
| | - E Holler
- Department of Hematology and Oncology, Internal Medicine III, University Medical Center, Regensburg, Germany
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88
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Impact of Gut Colonization by Antibiotic-Resistant Bacteria on the Outcomes of Allogeneic Hematopoietic Stem Cell Transplantation: A Retrospective, Single-Center Study. Biol Blood Marrow Transplant 2016; 22:1087-1093. [PMID: 26900084 DOI: 10.1016/j.bbmt.2016.02.009] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/12/2016] [Indexed: 12/19/2022]
Abstract
Gut colonization by antibiotic-resistant bacteria may underlie hard-to-treat systemic infections. There is also accumulating evidence on the immunomodulatory function of gut microbiota after allogeneic stem cell transplantation (alloSCT) and its impact on graft-versus-host disease (GVHD). We investigated the epidemiology and clinical impact of gut colonization after alloSCT and retrospectively analyzed data on 107 alloSCTs performed at a single transplant center. Pretransplant microbiology screening identified colonization in 31% of cases. Colonization had a negative impact on overall survival after alloSCT in univariate (34% versus 74% at 24 months, P < .001) and multivariate (hazard ratio, 3.53; 95% confidence interval, 1.71 to 7.28; P < .001) analyses. Nonrelapse mortality was significantly higher in colonized than in noncolonized patients (42% versus 11% at 24 months, P = .001). Colonized patients more frequently experienced bacteremia (48% versus 24%, P = .01), and more deaths were attributable to infectious causes in the colonized group (42% versus 11% of patients and 67% versus 29% of deaths, P < .05). We observed a significantly higher incidence of grades II to IV acute GVHD in colonized than in noncolonized patients (42% versus 23%, P < .05), especially involving the gastrointestinal system (33% versus 13.5%, P = .07). In summary, we determined that gut colonization by antibiotic-resistant bacteria decreases the overall survival of patients undergoing alloSCT by increasing nonrelapse mortality and the incidences of systemic infection and acute GVHD.
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89
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Andermann TM, Rezvani A, Bhatt AS. Microbiota Manipulation With Prebiotics and Probiotics in Patients Undergoing Stem Cell Transplantation. Curr Hematol Malig Rep 2016; 11:19-28. [PMID: 26780719 PMCID: PMC4996265 DOI: 10.1007/s11899-016-0302-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potentially life-saving therapy that often comes at the cost of complications such as graft-versus-host disease and post-transplant infections. With improved technology to understand the ecosystem of microorganisms (viruses, bacteria, fungi, and microeukaryotes) that make up the gut microbiota, there is increasing evidence of the microbiota's contribution to the development of post-transplant complications. Antibiotics have traditionally been the mainstay of microbiota-altering therapies available to physicians. Recently, interest is increasing in the use of prebiotics and probiotics to support the development and sustainability of a healthier microbiota. In this review, we will describe the evidence for the use of prebiotics and probiotics in combating microbiota dysbiosis and explore the ways in which they may be used in future research to potentially improve clinical outcomes and decrease rates of graft-versus-host disease (GVHD) and post-transplant infection.
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Affiliation(s)
- Tessa M Andermann
- Department of Medicine, Division of Infectious Diseases, Stanford University, Stanford, CA, USA
| | - Andrew Rezvani
- Department of Medicine, Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA, USA
| | - Ami S Bhatt
- Department of Medicine, Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA, USA.
- Department of Medicine, Division of Hematology, Stanford University, 269 Campus Drive, Stanford, CA, 94305, USA.
- Department of Genetics, Stanford University, Stanford, CA, USA.
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91
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Allogeneic hematopoietic cell transplantation without fluconazole and fluoroquinolone prophylaxis. Ann Hematol 2015; 95:287-93. [DOI: 10.1007/s00277-015-2535-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 10/17/2015] [Indexed: 10/22/2022]
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92
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Reactivation of Human Herpes Virus-6 After Pediatric Stem Cell Transplantation: Risk Factors, Onset, Clinical Symptoms and Association With Severity of Acute Graft-Versus-Host Disease. Pediatr Infect Dis J 2015; 34:1118-27. [PMID: 26132825 DOI: 10.1097/inf.0000000000000824] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND METHODS To study clinical symptoms, timing and consequences of human herpesvirus-6 (HHV-6) reactivation after pediatric allogeneic stem cell transplantation (SCT), HHV-6 was investigated by plasma polymerase chain reaction in a cohort of 106 pediatric SCT recipients. RESULTS HHV-6 viremia was detected post-SCT in 48% of the patients with a median time of onset at 20 days after SCT. In week 3 and 4 post-SCT, HHV-6 is the most common infectious agent detected. In up to 30% of the patients with fever of unknown origin, HHV-6 was the only detected infectious agent to explain fever. Patients transplanted with an unrelated donor or receiving serotherapy were at increased risk of HHV-6 reactivation. The onset of HHV-6 reactivation coincided with the appearance of lymphocytes and monocytes in peripheral blood. Treatment with alemtuzumab (MabCampath) delayed both lymphocyte and monocyte engraftment and, concomitantly, onset of HHV-6 reactivation was delayed in those cases. HHV-6 reactivation was not associated with an increased incidence of acute graft-versus-host disease (GvHD). However, progression to grade II-IV GvHD was in 9 of 10 patients associated with HHV-6 reactivation before GvHD (P = 0.006) and HHV-6 was the only infection with such an association. CONCLUSIONS HHV-6 frequently reactivates after pediatric SCT around the time of mononuclear cell engraftment and is associated with an increased severity of GvHD. HHV-6 may explain fever of unknown origin in 30% of the patients early after SCT. Assessment of HHV-6 reactivation in patients early after SCT can be instrumental for clinical decision making.
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93
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Henden AS, Hill GR. Cytokines in Graft-versus-Host Disease. THE JOURNAL OF IMMUNOLOGY 2015; 194:4604-12. [PMID: 25934923 DOI: 10.4049/jimmunol.1500117] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Graft-versus-host disease (GVHD) is a complication of allogeneic bone marrow transplantation whereby transplanted naive and marrow-derived T cells damage recipient tissue through similar mechanisms to those that allow destruction of malignant cells, the therapeutic intent of bone marrow transplantation. The manifestations and severity of GVHD are highly variable and are influenced by the proportions of naive cells maturing along regulatory T cell, Th1, Th2, or Th17 phenotypes. This maturation is largely influenced by local cytokines, which, in turn, activate transcription factors and drive development toward a dominant phenotype. In addition, proinflammatory cytokines exert direct effects on GVHD target tissues. Our knowledge of the role that cytokines play in orchestrating GVHD is expanding rapidly and parallels other infective and inflammatory conditions in which a predominant T cell signature is causative of pathology. Because a broad spectrum of cytokine therapies is now routinely used in clinical practice, they are increasingly relevant to transplant medicine.
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Affiliation(s)
- Andrea S Henden
- Bone Marrow Transplantation Laboratory, QIMR Berghofer Medical Research Institute, Brisbane 4006, Queensland, Australia; and The Royal Brisbane and Women's Hospital, Brisbane 4029, Queensland, Australia
| | - Geoffrey R Hill
- Bone Marrow Transplantation Laboratory, QIMR Berghofer Medical Research Institute, Brisbane 4006, Queensland, Australia; and The Royal Brisbane and Women's Hospital, Brisbane 4029, Queensland, Australia
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94
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Jenq RR, Taur Y, Devlin SM, Ponce DM, Goldberg JD, Ahr KF, Littmann ER, Ling L, Gobourne AC, Miller LC, Docampo MD, Peled JU, Arpaia N, Cross JR, Peets TK, Lumish MA, Shono Y, Dudakov JA, Poeck H, Hanash AM, Barker JN, Perales MA, Giralt SA, Pamer EG, van den Brink MRM. Intestinal Blautia Is Associated with Reduced Death from Graft-versus-Host Disease. Biol Blood Marrow Transplant 2015; 21:1373-83. [PMID: 25977230 DOI: 10.1016/j.bbmt.2015.04.016] [Citation(s) in RCA: 531] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 04/13/2015] [Indexed: 02/07/2023]
Abstract
The relationship between intestinal microbiota composition and acute graft-versus-host disease (GVHD) after allogeneic blood/marrow transplantation (allo-BMT) is not well understood. Intestinal bacteria have long been thought to contribute to GVHD pathophysiology, but recent animal studies in nontransplant settings have found that anti-inflammatory effects are mediated by certain subpopulations of intestinal commensals. Hypothesizing that a more nuanced relationship may exist between the intestinal bacteria and GVHD, we evaluated the fecal bacterial composition of 64 patients 12 days after BMT. We found that increased bacterial diversity was associated with reduced GVHD-related mortality. Furthermore, harboring increased amounts of bacteria belonging to the genus Blautia was associated with reduced GVHD lethality in this cohort and was confirmed in another independent cohort of 51 patients from the same institution. Blautia abundance was also associated with improved overall survival. We evaluated the abundance of Blautia with respect to clinical factors and found that loss of Blautia was associated with treatment with antibiotics that inhibit anaerobic bacteria and receiving total parenteral nutrition for longer durations. We conclude that increased abundance of commensal bacteria belonging to the Blautia genus is associated with reduced lethal GVHD and improved overall survival.
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Affiliation(s)
- Robert R Jenq
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
| | - Ying Taur
- Weill Cornell Medical College, New York, New York; Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Doris M Ponce
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Jenna D Goldberg
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Katya F Ahr
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Eric R Littmann
- Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lilan Ling
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Asia C Gobourne
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Liza C Miller
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa D Docampo
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan U Peled
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Nicholas Arpaia
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Justin R Cross
- Cell Metabolism Core, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Tatanisha K Peets
- Department of Nutrition, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa A Lumish
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yusuke Shono
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jarrod A Dudakov
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hendrik Poeck
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alan M Hanash
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Juliet N Barker
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Sergio A Giralt
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Eric G Pamer
- Weill Cornell Medical College, New York, New York; Infectious Diseases Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcel R M van den Brink
- Adult BMT, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
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95
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Bernardes PTT, Rezende BM, Resende CB, De Paula TP, Reis AC, Gonçalves WA, Vieira EG, Pinheiro MVB, Souza DG, Castor MGM, Teixeira MM, Pinho V. Nanocomposite treatment reduces disease and lethality in a murine model of acute graft-versus-host disease and preserves anti-tumor effects. PLoS One 2015; 10:e0123004. [PMID: 25875016 PMCID: PMC4395348 DOI: 10.1371/journal.pone.0123004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 02/26/2015] [Indexed: 12/21/2022] Open
Abstract
Graft versus host disease (GVHD) is an immunological disorder triggered by bone marrow transplantation that affects several organs, including the gastrointestinal tract and liver. Fullerenes and their soluble forms, fullerols, are nanocomposites with a closed symmetrical structure with anti-inflammatory and anti-oxidant properties. The present study evaluated the effects of treatment with the fullerol (C60(OH)18-20) in the development and pathogenesis of GVHD in a murine model. Mice with experimental GVHD that were treated with the fullerol showed reduced clinical signs of disease and mortality compared with untreated mice. Treatment with the fullerol decreased the hepatic damage associated with reduced hepatic levels of reactive oxygen species, pro-inflammatory cytokines and chemokines (IFN-γ TNF-α, CCL2, CCL3 and CCL5) and reduced leukocyte accumulation. The amelioration of GVHD after treatment with the fullerol was also associated with reduced intestinal lesions and consequent bacterial translocation to the blood, liver and peritoneal cavity. Moreover, the fullerol treatment alleviated the GVHD while preserving effects of the graft against a leukemia cell line (GFP+P815). In summary, the fullerol was effective in reducing the GVHD inflammatory response in mice and may suggest novel ways to treat this disease.
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Affiliation(s)
- Priscila T. T. Bernardes
- Laboratório de Resolução da Resposta Inflamatória, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Bárbara M. Rezende
- Laboratório de Resolução da Resposta Inflamatória, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Carolina B. Resende
- Laboratório de Resolução da Resposta Inflamatória, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Talles P. De Paula
- Laboratório de Interação Microorganismo e Hospedeiro, Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Alesandra C. Reis
- Laboratório de Resolução da Resposta Inflamatória, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - William A. Gonçalves
- Laboratório de Resolução da Resposta Inflamatória, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Elias G. Vieira
- Laboratório de Ressonância Paramagnética, Departamento de Física Instituto de Ciências Exatas,Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Maurício V. B. Pinheiro
- Laboratório de Ressonância Paramagnética, Departamento de Física Instituto de Ciências Exatas,Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Danielle G. Souza
- Laboratório de Interação Microorganismo e Hospedeiro, Departamento de Microbiologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Marina G. M. Castor
- Laboratório de Resolução da Resposta Inflamatória, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Mauro M. Teixeira
- Laboratório de Imunofarmacologia, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Vanessa Pinho
- Laboratório de Resolução da Resposta Inflamatória, Departamento de Morfologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- * E-mail:
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96
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Shono Y, Docampo MD, Peled JU, Perobelli SM, Jenq RR. Intestinal microbiota-related effects on graft-versus-host disease. Int J Hematol 2015; 101:428-37. [PMID: 25812838 DOI: 10.1007/s12185-015-1781-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/16/2015] [Indexed: 12/18/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an increasingly important treatment for conditions including hematopoietic malignancies and inherited hematopoietic disorders, and is considered to be the most effective form of tumor immunotherapy available to date. However, graft-versus-host disease (GVHD) remains a major source of morbidity and mortality following allo-HSCT, and understanding the mechanisms of GVHD has been highlighted as a key research priority. During development of GVHD, activation of various immune cells, especially donor T cells, leads to damage of target organs including skin, liver, hematopoietic system, and of particular clinical importance, gut. In addition to histocompatibility complex differences between the donor and recipient, pretransplant conditioning with chemotherapy and irradiation also contributes to GVHD by damaging the gut, resulting in systemic exposure to microbial products normally confined to the intestinal lumen. The intestinal microbiota is a modulator of gastrointestinal immune homeostasis. It also promotes the maintenance of epithelial cells. Recent reports provide growing evidence of the impact of intestinal microbiota on GVHD pathophysiology. This review summarizes current knowledge of changes and effects of intestinal microbiota in the setting of allo-HSCT. We will also discuss potential future strategies of intestinal microbiota manipulation that might be advantageous in decreasing allo-HSCT-related morbidity and mortality.
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Affiliation(s)
- Yusuke Shono
- Department of Immunology, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA,
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97
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α-Mannan induces Th17-mediated pulmonary graft-versus-host disease in mice. Blood 2015; 125:3014-23. [PMID: 25740827 DOI: 10.1182/blood-2014-12-615781] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/23/2015] [Indexed: 12/11/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative therapy for various hematopoietic disorders. Graft-versus-host disease (GVHD) and infections are the major obstacles of HSCT, and their close relationship has been suggested. Although roles of bacterial and viral infections in the pathophysiology of GVHD are well described, impacts of fungal infection on GVHD remain to be elucidated. In mouse models of GVHD, injection of α-mannan (Mn), a major component of fungal cell wall, or heat-killed Candida albicans exacerbated GVHD, particularly in the lung. Mn-induced donor T-cell polarization toward Th17 and lung-specific chemokine environment in GVHD led to accumulation of Th17 cells in the lung. The detrimental effects of Mn on GVHD depended on donor IL-17A production and host C-type lectin receptor Dectin-2. These results suggest a previously unrecognized link between pulmonary GVHD and fungal infection after allogeneic HSCT.
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98
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Sporrer D, Gessner A, Hehlgans T, Oefner PJ, Holler E. The Microbiome and Allogeneic Stem Cell Transplantation. CURRENT STEM CELL REPORTS 2015. [DOI: 10.1007/s40778-014-0006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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99
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Nalle SC, Kwak HA, Edelblum KL, Joseph NE, Singh G, Khramtsova GF, Mortenson ED, Savage PA, Turner JR. Recipient NK cell inactivation and intestinal barrier loss are required for MHC-matched graft-versus-host disease. Sci Transl Med 2015; 6:243ra87. [PMID: 24990882 DOI: 10.1126/scitranslmed.3008941] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Previous studies have shown a correlation between pretransplant conditioning intensity, intestinal barrier loss, and graft-versus-host disease (GVHD) severity. However, because irradiation and other forms of pretransplant conditioning have pleiotropic effects, the precise role of intestinal barrier loss in GVHD pathogenesis remains unclear. We developed GVHD models that allowed us to isolate the specific contributions of distinct pretransplant variables. Intestinal damage was required for the induction of minor mismatch [major histocompatibility complex (MHC)-matched] GVHD, but was not necessary for major mismatch GVHD, demonstrating fundamental pathogenic distinctions between these forms of disease. Moreover, recipient natural killer (NK) cells prevented minor mismatch GVHD by limiting expansion and target organ infiltration of alloreactive T cells via a perforin-dependent mechanism, revealing an immunoregulatory function of MHC-matched recipient NK cells in GVHD. Minor mismatch GVHD required MyD88-mediated Toll-like receptor 4 (TLR4) signaling on donor cells, and intestinal damage could be bypassed by parenteral lipopolysaccharide (LPS) administration, indicating a critical role for the influx of bacterial components triggered by intestinal barrier loss. In all, the data demonstrate that pretransplant conditioning plays a dual role in promoting minor mismatch GVHD by both depleting recipient NK cells and inducing intestinal barrier loss.
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Affiliation(s)
- Sam C Nalle
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
| | - H Aimee Kwak
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
| | - Karen L Edelblum
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
| | - Nora E Joseph
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
| | - Gurminder Singh
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
| | | | - Eric D Mortenson
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
| | - Peter A Savage
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA.
| | - Jerrold R Turner
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA.
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100
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Galvani RG, Lemos R, Areal RB, Salvador PA, Zamboni DS, Wanderley JLM, Bonomo A. Disease severity and mortality can be independently regulated in a mouse model of experimental graft versus host disease. PLoS One 2015; 10:e0118079. [PMID: 25643148 PMCID: PMC4313938 DOI: 10.1371/journal.pone.0118079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 01/05/2015] [Indexed: 12/16/2022] Open
Abstract
Graft versus host disease (GVHD) is the major limitation of allogeneic hematopoietic stem cell transplantation (HSCT) presenting high mortality and morbidity rates. However, the exact cause of death is not completely understood and does not correlate with specific clinical and histological parameters of disease. Here we show, by using a semi-allogeneic mouse model of GVHD, that mortality and morbidity can be experimentally separated. We injected bone marrow-derived dendritic cells (BMDC) from NOD2/CARD15-deficient donors into semi-allogeneic irradiated chimaeras and observed that recipients were protected from death. However, no protection was observed regarding clinical or pathological scores up to 20 days after transplantation. Protection from death was associated with decreased bacterial translocation, faster hematologic recovery and epithelial integrity maintenance despite mononuclear infiltration at day 20 post-GVHD induction with no skew towards different T helper phenotypes. The protected mice recovered from aGVHD and progressively reached scores compatible with healthy animals. Altogether, our data indicate that severity and mortality can be separate events providing a model to study transplant-related mortality.
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Affiliation(s)
- Rômulo G. Galvani
- Divisão de Medicina Experimental, Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
- Departamento de Imunologia, Instituto de Microbiologia Professor Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ramon Lemos
- Divisão de Medicina Experimental, Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
- Departamento de Imunologia, Instituto de Microbiologia Professor Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rômulo B. Areal
- Divisão de Medicina Experimental, Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Pollyanna A. Salvador
- Divisão de Medicina Experimental, Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
| | - Dario S. Zamboni
- Departamento de Biologia Celular, Molecular e Bioagentes Patogênicos, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | - João Luiz M. Wanderley
- Divisão de Medicina Experimental, Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
- NUPEM, Campus Macaé Professor Aloísio Teixeira, Universidade Federal do Rio de Janeiro, Macaé, Rio de Janeiro, Brazil
- * E-mail:
| | - Adriana Bonomo
- Divisão de Medicina Experimental, Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, Brazil
- Departamento de Imunologia, Instituto de Microbiologia Professor Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Laboratorio de Pesquisa sobre o Timo, Instituo Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil
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