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Bubik RJ, Dierkhising RA, Mara KC, Daly RC, Kushwaha SS, Clavell AL, Bernard SA. Malignancy among adult heart transplant recipients following patient-tailored dosing of anti-thymocyte globulin: a retrospective, nested case-control study of individualized dosing. Transpl Int 2021; 34:2175-2183. [PMID: 34411345 DOI: 10.1111/tri.14012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 11/29/2022]
Abstract
Post-transplant malignancy is diagnosed in approximately 18% of heart transplant patients and is a leading cause of death post-transplant. One modifiable risk factor is the type and amount of immunosuppression received. Contemporary rabbit anti-thymocyte globulin (rATG) dosing strategy using T-cell-guided dosing, and its effect on malignancy in heart transplant patients is unclear. This was a single-center, retrospective chart review of heart transplant recipients receiving rATG for induction. Patients diagnosed with malignancy post-transplant were matched 1:2 to controls using a nested case-control design. The primary endpoint was to determine the relative risk of rATG exposure with the actual incidence of malignancy post-transplant. The secondary endpoint was the impact of maintenance immunosuppression on malignancy risk. Of the 126 patients included in the study, 25 developed malignancy and were matched to 50 control patients. The median cumulative rATG dose in milligrams (mg) between groups was 365 mg in malignancy cases and 480 mg in controls (OR 0.90, 95% CI 0.75-1.08, P = 0.28). In both the univariate and multivariable analysis, there was no statistically significant difference in malignancy risk found with any maintenance immunosuppressant. The results of this study showed that patient-tailored rATG dosing strategies may not be associated with malignancy development as previously thought.
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Affiliation(s)
| | - Ross A Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.,Divison of Transplantation Surgery, Mayo Clinic, Rochester, MN, USA
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102
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Immunologic effects on the haematopoietic stem cell in marrow failure. Best Pract Res Clin Haematol 2021; 34:101276. [PMID: 34404528 DOI: 10.1016/j.beha.2021.101276] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
Acquired bone marrow failure (BMF) syndromes comprise a diverse group of diseases with variable clinical manifestations but overlapping features of immune activation, resulting in haematopoietic stem and progenitor cells (HSPC) damage and destruction. This review focuses on clinical presentation, pathophysiology, and treatment of four BMF: acquired aplastic anaemia, large granular lymphocytic leukaemia, paroxysmal nocturnal haemoglobinuria, and hypoplastic myelodysplastic syndrome. Autoantigens are speculated to be the inciting event that result in immune activation in all of these diseases, but specific pathogenic antigens have not been identified. Oligoclonal cytotoxic T cell expansion and an active role of proinflammatory cytokines, primarily interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF-α), are two main contributors to HSPC growth inhibition and apoptosis in BMF. Emerging evidence also suggests involvement of the innate immune system.
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103
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Wang M, Fang X, Jiang Y, Sui X, Li Y, Liu X, Wang X, Li P, Xu H, Wang X. Comparison of 2 Different Doses of Antithymocyte Globulin in Conditioning Regimens for Haploidentical Hematopoietic Stem Cell Transplantation. EXP CLIN TRANSPLANT 2021; 20:69-76. [PMID: 34387153 DOI: 10.6002/ect.2021.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Antithymocyte globulin is extensively used for prophylaxis of graft-versus-host disease in patients undergoing haploidentical hematopoietic stem cell transplantation. However, different doses of antithymocyte globulin are administered in clinical practice. This study aimed to identify the optimal dose of antithymocyte globulin (thymoglobulin) in haploidentical hematopoietic stem cell transplantation. MATERIALS AND METHODS We retrospectively analyzed the effects of 10 mg/kg (2.5 mg/kg on days -5 to -2) versus 7.5 mg/kg thymoglobulin (2.5 mg/kg on days -4 to -2) on patients receiving haploidentical hematopoietic stem cell transplantation with myeloablative conditioning. RESULTS We observed significant differences between the 2 treatment groups with regard to cumulative incidence of grade II to IV acute graft-versus-host disease (15.3% vs 14.6%; P = .93) and 3-year chronic graft-versus-host disease (12.1% vs 14.3%; P = .77). The probabilities of 3-year overall survival (68.9% vs 73.5%; P = .98) and graft-versus-host disease-free/relapse-free survival (66.7% vs 53.1%; P = .14) were comparable between the 2 groups. However, there was a trend for lower cumulative incidence of hemorrhagic cystitis in the 7.5 mg/kg treatment group compared with the 10 mg/kg treatment group (40.7% vs 24.4%; P = .07). CONCLUSIONS For patients who received a reduced dose of antithymocyte globulin (7.5 vs 10 mg/kg), there was no impaired effect on prophylaxis of graft-versus-host disease, with a trend of reduced incidence of hemorrhagic cystitis. Further studies of the 7.5 mg/kg dose of antithymocyte globulin are warranted for patients receiving haploidentical hematopoietic stem cell transplantation.
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Affiliation(s)
- Mingyang Wang
- From the Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,the Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,the State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin,China
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104
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Bluestone JA, Buckner JH, Herold KC. Immunotherapy: Building a bridge to a cure for type 1 diabetes. Science 2021; 373:510-516. [PMID: 34326232 DOI: 10.1126/science.abh1654] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Type 1 diabetes (T1D) is an autoimmune disease in which T cells attack and destroy the insulin-producing β cells in the pancreatic islets. Genetic and environmental factors increase T1D risk by compromising immune homeostasis. Although the discovery and use of insulin have transformed T1D treatment, insulin therapy does not change the underlying disease or fully prevent complications. Over the past two decades, research has identified multiple immune cell types and soluble factors that destroy insulin-producing β cells. These insights into disease pathogenesis have enabled the development of therapies to prevent and modify T1D. In this review, we highlight the key events that initiate and sustain pancreatic islet inflammation in T1D, the current state of the immunological therapies, and their advantages for the treatment of T1D.
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Affiliation(s)
- Jeffrey A Bluestone
- UCSF Diabetes Center, University of California San Francisco, San Francisco, CA 94143, USA
| | - Jane H Buckner
- Center for Translational Immunology, Benaroya Research Institute (BRI) at Virginia Mason, Seattle, WA, USA.,Department of Immunology, University of Washington School of Medicine, Seattle, WA 98101, USA
| | - Kevan C Herold
- Department of Immunobiology and Department of Internal Medicine, Yale University, New Haven, CT 06520, USA
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105
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Bikhet M, Iwase H, Yamamoto T, Jagdale A, Foote JB, Ezzelarab M, Anderson DJ, Locke JE, Eckhoff DE, Hara H, Cooper DKC. What Therapeutic Regimen Will Be Optimal for Initial Clinical Trials of Pig Organ Transplantation? Transplantation 2021; 105:1143-1155. [PMID: 33534529 DOI: 10.1097/tp.0000000000003622] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We discuss what therapeutic regimen might be acceptable/successful in the first clinical trial of genetically engineered pig kidney or heart transplantation. As regimens based on a calcineurin inhibitor or CTLA4-Ig have proved unsuccessful, the regimen we administer to baboons is based on induction therapy with antithymocyte globulin, an anti-CD20 mAb (Rituximab), and cobra venom factor, with maintenance therapy based on blockade of the CD40/CD154 costimulation pathway (with an anti-CD40 mAb), with rapamycin, and a corticosteroid. An anti-inflammatory agent (etanercept) is administered for the first 2 wk, and adjuvant therapy includes prophylaxis against thrombotic complications, anemia, cytomegalovirus, and pneumocystis. Using this regimen, although antibody-mediated rejection certainly can occur, we have documented no definite evidence of an adaptive immune response to the pig xenograft. This regimen could also form the basis for the first clinical trial, except that cobra venom factor will be replaced by a clinically approved agent, for example, a C1-esterase inhibitor. However, none of the agents that block the CD40/CD154 pathway are yet approved for clinical use, and so this hurdle remains to be overcome. The role of anti-inflammatory agents remains unproven. The major difference between this suggested regimen and those used in allotransplantation is the replacement of a calcineurin inhibitor with a costimulation blockade agent, but this does not appear to increase the complications of the regimen.
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Affiliation(s)
- Mohamed Bikhet
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hayato Iwase
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Takayuki Yamamoto
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Abhijit Jagdale
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jeremy B Foote
- Department of Microbiology and Animal Resources Program, University of Alabama at Birmingham, Birmingham, AL
| | - Mohamed Ezzelarab
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Douglas J Anderson
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jayme E Locke
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Devin E Eckhoff
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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106
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Peraro L, Bourne CM, Dacek MM, Akalin E, Park JH, Smith EL, Scheinberg DA. Incorporation of bacterial immunoevasins to protect cell therapies from host antibody-mediated immune rejection. Mol Ther 2021; 29:3398-3409. [PMID: 34217891 DOI: 10.1016/j.ymthe.2021.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/27/2021] [Accepted: 06/25/2021] [Indexed: 10/21/2022] Open
Abstract
Cellular therapies are engineered using foreign and synthetic protein sequences, such as chimeric antigen receptors. The frequently observed humoral responses to CAR T cells result in rapid clearance, especially after re-infusions. There is an unmet need to protect engineered cells from host-versus-graft rejection, particularly for the advancement of allogeneic cell therapies. Here, utilizing the IgG protease "IdeS", we programmed CAR T cells to defeat humoral immune attacks. IdeS cleavage of host IgG averted Fc-dependent phagocytosis and lysis, and the residual F(ab')2 fragments remained on the surface, providing cells with an inert shield from additional IgG deposition. "Shield" CAR T cells efficiently cleaved cytotoxic IgG, including anti-CAR antibodies, detected in patient samples and provided effective anti-tumor activity in the presence of anti-cell IgG in vivo. This technology may be useful for repeated human infusions of engineered cells, more complex engineered cells, and expanding widespread use of "off-the-shelf" allogeneic cellular therapies.
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Affiliation(s)
- Leila Peraro
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065
| | - Christopher M Bourne
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065; Weill Cornell Medicine, New York, NY 10065
| | - Megan M Dacek
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065; Weill Cornell Medicine, New York, NY 10065
| | - Enver Akalin
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467
| | - Jae H Park
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065
| | - Eric L Smith
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065
| | - David A Scheinberg
- Memorial Sloan-Kettering Cancer Center, New York, NY 10065; Weill Cornell Medicine, New York, NY 10065.
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107
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Ritschl PV, Günther J, Hofhansel L, Ernst S, Ebner S, Sattler A, Weiß S, Weissenbacher A, Oberhuber R, Cardini B, Öllinger R, Biebl M, Denecke C, Margreiter C, Resch T, Schneeberger S, Maglione M, Kotsch K, Pratschke J. Perioperative Perfusion of Allografts with Anti-Human T-lymphocyte Globulin Does Not Improve Outcome Post Liver Transplantation-A Randomized Placebo-Controlled Trial. J Clin Med 2021; 10:jcm10132816. [PMID: 34202355 PMCID: PMC8267618 DOI: 10.3390/jcm10132816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/05/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
Due to the lack of suitable organs transplant surgeons have to accept unfavorable extended criteria donor (ECD) organs. Recently, we demonstrated that the perfusion of kidney organs with anti-human T-lymphocyte globulin (ATLG) prior to transplantation ameliorates ischemia-reperfusion injury (IRI). Here, we report on the results of perioperative ATLG perfusion in a randomized, single-blinded, placebo-controlled, feasibility trial (RCT) involving 30 liver recipients (LTx). Organs were randomly assigned for perfusion with ATLG/Grafalon® (AP) (n = 16) or saline only (control perfusion = CP) (n = 14) prior to implantation. The primary endpoint was defined as graft function reflected by aspartate transaminase (AST) values at day 7 post-transplantation (post-tx). With respect to the primary endpoint, no significant differences in AST levels were shown in the intervention group at day 7 (AP: 53.0 ± 21.3 mg/dL, CP: 59.7 ± 59.2 mg/dL, p = 0.686). Similarly, exploratory analysis of secondary clinical outcomes (e.g., patient survival) and treatment-specific adverse events revealed no differences between the study groups. Among liver transplant recipients, pre-operative organ perfusion with ATLG did not improve short-term outcomes, compared to those who received placebo perfusion. However, ATLG perfusion of liver grafts was proven to be a safe procedure without the occurrence of relevant adverse events.
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Affiliation(s)
- Paul Viktor Ritschl
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
- Clinician Scientist Program, Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Str. 2, 10178 Berlin, Germany
| | - Julia Günther
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Lena Hofhansel
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
- Department of Psychiatry, Psychotherapy and Psychosomatics, Faculty of Medicine, RWTH Aachen, 52074 Aachen, Germany
| | - Stefanie Ernst
- Biostatistics Unit, Clinical Research Unit, Berlin Institute of Health, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Susanne Ebner
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Arne Sattler
- Department of General, Visceral- and Vascular Surgery, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, 12203 Berlin, Germany;
| | - Sascha Weiß
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Annemarie Weissenbacher
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Rupert Oberhuber
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Benno Cardini
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Robert Öllinger
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Matthias Biebl
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Christian Denecke
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
| | - Christian Margreiter
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Thomas Resch
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Stefan Schneeberger
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Manuel Maglione
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, 5020 Innsbruck, Austria; (J.G.); (L.H.); (S.E.); (A.W.); (R.O.); (B.C.); (C.M.); (T.R.); (S.S.); (M.M.)
| | - Katja Kotsch
- Department of General, Visceral- and Vascular Surgery, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, 12203 Berlin, Germany;
- Correspondence: ; Tel.: +49-30-450-552247
| | - Johann Pratschke
- Department of Surgery, Campus Charité-Mitte and Campus Virchow-Klinikum, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (P.V.R.); (S.W.); (R.Ö.); (M.B.); (C.D.); (J.P.)
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108
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Vinson A, Teixeira A, Kiberd B, Tennankore K. Predictors and Complications of Post Kidney Transplant Leukopenia. Prog Transplant 2021; 31:249-256. [PMID: 34159855 DOI: 10.1177/15269248211024614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Leukopenia occurs frequently following kidney transplantation and is associated with adverse clinical outcomes including increased infectious risk. In this study we sought to characterize the causes and complications of leukopenia following kidney transplantation. METHODS In a cohort of adult patients (≥18 years) who underwent kidney transplant from Jan 2006-Dec 2017, we used univariable Cox proportional Hazards models to identify predictors of post-transplant leukopenia (WBC < 3500 mm3). Factors associated with post-transplant leukopenia were then included in a multivariable backwards stepwise selection process to create a prediction model for the outcome of interest. Cox regression analyses were subsequently used to determine if post-transplant leukopenia was associated with complications. RESULTS Of 388 recipients, 152 (39%) developed posttransplant leukopenia. Factors associated with leukopenia included antithymocyte globulin as induction therapy (HR 3.32, 95% CI 2.25-4.91), valganciclovir (HR 1.84, 95% CI 1.25-2.70), tacrolimus (HR 3.05, 95% CI 1.08-8.55), prior blood transfusion (HR 1.17 per unit, 95% CI 1.09- 1.25), and donor age (HR 1.02 per year, 95% CI 1.00-1.03). Cytomegalovirus infection occurred in 26 patients with leukopenia (17.1%). Other than cytomegalovirus, leukopenia was not associated with posttransplant complications. CONCLUSION Leukopenia commonly occurred posttransplant and was associated with modifiable and non-modifiable pretransplant factors.
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Affiliation(s)
- Amanda Vinson
- 432234Nova Scotia Health Authority Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alyne Teixeira
- School of Biomedical Engineering, 3688Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bryce Kiberd
- 432234Nova Scotia Health Authority Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karthik Tennankore
- 432234Nova Scotia Health Authority Division of Nephrology, Dalhousie University, Halifax, Nova Scotia, Canada
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109
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Russell AL, Prince C, Lundgren TS, Knight KA, Denning G, Alexander JS, Zoine JT, Spencer HT, Chandrakasan S, Doering CB. Non-genotoxic conditioning facilitates hematopoietic stem cell gene therapy for hemophilia A using bioengineered factor VIII. Mol Ther Methods Clin Dev 2021; 21:710-727. [PMID: 34141826 PMCID: PMC8181577 DOI: 10.1016/j.omtm.2021.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/29/2021] [Indexed: 01/09/2023]
Abstract
Hematopoietic stem and progenitor cell (HSPC) lentiviral gene therapy is a promising strategy toward a lifelong cure for hemophilia A (HA). The primary risks associated with this approach center on the requirement for pre-transplantation conditioning necessary to make space for, and provide immune suppression against, stem cells and blood coagulation factor VIII, respectively. Traditional conditioning agents utilize genotoxic mechanisms of action, such as DNA alkylation, that increase risk of sterility, infection, and developing secondary malignancies. In the current study, we describe a non-genotoxic conditioning protocol using an immunotoxin targeting CD117 (c-kit) to achieve endogenous hematopoietic stem cell depletion and a cocktail of monoclonal antibodies to provide transient immune suppression against the transgene product in a murine HA gene therapy model. This strategy provides high-level engraftment of hematopoietic stem cells genetically modified ex vivo using recombinant lentiviral vector (LV) encoding a bioengineered high-expression factor VIII variant, termed ET3. Factor VIII procoagulant activity levels were durably elevated into the normal range and phenotypic correction achieved. Furthermore, no immunological rejection or development of anti-ET3 immunity was observed. These preclinical data support clinical translation of non-genotoxic antibody-based conditioning in HSPC LV gene therapy for HA.
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Affiliation(s)
- Athena L. Russell
- Graduate Program in Genetics and Molecular Biology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | - Chengyu Prince
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Taran S. Lundgren
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | - Kristopher A. Knight
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | | | - Jordan S. Alexander
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jaquelyn T. Zoine
- Graduate Program in Cancer Biology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | - H. Trent Spencer
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Expression Therapeutics, LLC, Tucker, GA 30084, USA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Christopher B. Doering
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Expression Therapeutics, LLC, Tucker, GA 30084, USA
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110
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Kinch A, Baecklund E, Molin D, Pauksens K, Sundström C, Tufveson G, Enblad G. Prior antithymocyte globulin therapy and survival in post-transplant lymphoproliferative disorders. Acta Oncol 2021; 60:771-778. [PMID: 33793378 DOI: 10.1080/0284186x.2021.1904520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Treatment with antithymocyte globulin (ATG) is a well-recognized risk factor for the development of post-transplant lymphoproliferative disorders (PTLD) after solid organ transplantation, but it is unknown how its use affects overall survival after PTLD.Methods: A total of 114 patients with PTLD and available data on immunosuppressive regimen were included from a nation-wide case series of solid organ transplant recipients in Sweden. Prior use of ATG was correlated to clinical features, PTLD subtype, and survival.Results: A total of 47 (41%) patients had received ATG prior to the diagnosis of PTLD. The ATG-treated patients were more likely to be recipients of hearts or lungs, and less likely of kidneys (p < 0.01). They had experienced more acute rejections (p = 0.02). The PTLDs arose earlier, median 2.0 vs. 6.6 years post-transplant (p = 0.002) and were more often situated in the allograft (32% vs. 7%, p < 0.001) in patients with prior ATG vs. no ATG treatment. The PTLDs in the ATG group were more often Epstein-Barr virus-positive (80% vs. 40%, p < 0.001). There were more polymorphic PTLDs (17% vs. 1.5%, p = 0.004) and less T-cell PTLDs (4% vs. 19%, p = 0.02) in the ATG group than in the no ATG group. Diffuse large B-cell lymphoma was equally common in patients with and without prior ATG therapy, but the non-germinal center subtype was more frequent in the ATG group (p = 0.001). In an adjusted Cox proportional hazards regression model, prior ATG treatment and better performance status were associated with superior overall survival, whereas older age, T-cell subtype of PTLD, presence of B symptoms, and elevated lactate dehydrogenase were associated with inferior overall survival. Patients receiving ATG solely as rejection therapy had superior overall survival compared with those receiving ATG as induction therapy or both (p = 0.03).Conclusions: ATG therapy, especially rejection therapy, prior to PTLD development is an independent prognostic factor for superior overall survival after PTLD diagnosis.
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Affiliation(s)
- Amelie Kinch
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Eva Baecklund
- Department of Medical Sciences, Section of Rheumatology, Uppsala University, Uppsala, Sweden
| | - Daniel Molin
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Karlis Pauksens
- Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Christer Sundström
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Gunnar Tufveson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Gunilla Enblad
- Experimental and Clinical Oncology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
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111
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Allogeneic Stem Cell Transplantation Platforms With Ex Vivo and In Vivo Immune Manipulations: Count and Adjust. Hemasphere 2021; 5:e580. [PMID: 34095763 PMCID: PMC8171366 DOI: 10.1097/hs9.0000000000000580] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/14/2021] [Indexed: 01/16/2023] Open
Abstract
Various allogeneic (allo) stem cell transplantation platforms have been developed over the last 2 decades. In this review we focus on the impact of in vivo and ex vivo graft manipulation on immune reconstitution and clinical outcome. Strategies include anti-thymocyte globulin- and post-transplantation cyclophosphamide-based regimens, as well as graft engineering, such as CD34 selection and CD19/αβT cell depletion. Differences in duration of immune suppression, reconstituting immune repertoires, and associated graft-versus-leukemia effects and toxicities mediated through viral reactivations are highlighted. In addition, we discuss the impact of different reconstituting repertoires on donor lymphocyte infusions and post allo pharmacological interventions to enhance tumor control. We advocate for precisely counting all graft ingredients and therapeutic drug monitoring during conditioning in the peripheral blood, and for adjusting dosing accordingly on an individual basis. In addition, we propose novel trial designs to better assess the impact of variations in transplantation platforms in order to better learn from our diversity of “counts” and potential “adjustments.” This will, in the future, allow daily clinical practice, strategic choices, and future trial designs to be based on data guided decisions, rather than relying on dogma and habits.
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112
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Shaw BI, Schmitz R, Flores WJ, Magnani DM, Li J, Song M, Kirk AD. A comparative study of human-and rhesus-specific antithymocyte globulins in Rhesus macaques. Clin Transplant 2021; 35:e14369. [PMID: 34021521 DOI: 10.1111/ctr.14369] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 11/28/2022]
Abstract
Rabbit antithymocyte globulin (RATG) preparations are widely used in transplantation. They are developed in vivo against thymocytes and contain polyclonal antibodies specific for myriad cellular targets. The rhesus monkey is commonly used as a preclinical transplant model, but the fidelity of commercially available human-specific RATGs to anticipate the effects of RATGs in rhesus has not been established. We therefore developed two rhesus-specific ATGs (rhATG) and compared them to human-specific RATG (huATG, Thymoglobulin® ) in rhesus monkeys, assessing the magnitude and phenotype of depletion peripherally and in lymph nodes. Four primates were assigned to each group and received 20 mg/kg of drug. Depletion, repopulation, and changes in lymphocyte subsets were evaluated in peripheral blood and lymph nodes by flow cytometry over four months. We observed similar qualitative changes in lymphocyte subsets, but a generally more profound depletion with huATG compared to either rhATG. Peripheral homeostatic proliferation rather than thymic output was the major mechanism for repopulation with all RATGs. Repopulation was slower but qualitatively similar when examining RATGs in additional animals receiving concomitant chronic immunosuppression. Depletional induction is similar to human- and rhesus-specific RATGs in rhesus macaques. Both rhesus- and human-specific agents appear appropriate for preclinical modeling of clinical RATG use.
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Affiliation(s)
- Brian I Shaw
- Department of Surgery, Duke University, Durham, NC, USA
| | - Robin Schmitz
- Department of Surgery, Duke University, Durham, NC, USA
| | - Walter J Flores
- MassBiologics, University of Massachusetts Medical School, Boston, MA, USA
| | - Diogo M Magnani
- MassBiologics, University of Massachusetts Medical School, Boston, MA, USA
| | - Jie Li
- Department of Surgery, Duke University, Durham, NC, USA
| | - Mingqing Song
- Department of Surgery, Duke University, Durham, NC, USA
| | - Allan D Kirk
- Department of Surgery, Duke University, Durham, NC, USA
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113
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Cho HW, Ju HY, Hyun JK, Lee JW, Sung KW, Koo HH, Lim DH, Yoo KH. Conditioning with 10 Gy Total Body Irradiation, Cyclophosphamide, and Fludarabine without ATG Is Associated with Improved Outcome of Cord Blood Transplantation in Children with Acute Leukemia. J Korean Med Sci 2021; 36:e128. [PMID: 34002548 PMCID: PMC8129619 DOI: 10.3346/jkms.2021.36.e128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/07/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The optimal conditioning regimen in cord blood transplantation (CBT) needs to be determined. This study aimed to identify the impact of conditioning regimen on the outcome of CBT in children with acute leukemia. METHODS Medical records of patients with acute leukemia who received CBT were retrospectively reviewed. RESULTS A total of 71 patients were allocated into 2 groups; patients who received total body irradiation 10 Gy, cyclophosphamide 120 mg/kg, and fludarabine 75 mg/m² were named as TCF group (n = 18), while the non-TCF group (n = 53) included patients conditioned with regimens other than the TCF regimen. All patients in the TCF group were successfully engrafted, while 22.6% in the non-TCF group (n = 12) failed to achieve donor-origin hematopoiesis (P = 0.028). The incidence of cytomegalovirus diseases was 5.6% in the TCF group and 30.2% in the non-TCF group (P = 0.029). The 5-year overall survival rates of the TCF and non-TCF groups were 77.8% and 44.2%, respectively (P = 0.017). CONCLUSION Patients conditioned with the TCF regimen achieved better engraftment and survival rates, less suffering from cytomegalovirus disease. Our data suggest that the TCF regimen is a preferred option for CBT in children with acute leukemia.
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Affiliation(s)
- Hee Won Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Young Ju
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju Kyung Hyun
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Won Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Woong Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Hoe Koo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Stem Cell & Regenerative Medicine Institute, Samsung Medical Center, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keon Hee Yoo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Stem Cell & Regenerative Medicine Institute, Samsung Medical Center, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.
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Ali MM, Grønvold B, Remberger M, Abrahamsen IW, Myhre AE, Tjønnfjord GE, Fløisand Y, Gedde-Dahl T. Addition of Anti-thymocyte Globulin in Allogeneic Stem Cell Transplantation With Peripheral Stem Cells From Matched Unrelated Donors Improves Graft-Versus-Host Disease and Relapse Free Survival. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:598-605. [PMID: 34158268 DOI: 10.1016/j.clml.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
Anti-thymocyte globulin (ATG) is commonly used to prevent graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). To evaluate the impact of ATG as part of the GvHD prophylaxis in our institution, we report the outcome of 415 patients with matched unrelated donors (MUD) transplanted for hematological malignancies with or without ATG from 2005 to 2019 at Oslo University Hospital, Norway. The following groups were compared: (1) 154 patients transplanted with peripheral blood stem cells (PBSC) without ATG 2005-2014. (2) 137 patients transplanted with bone marrow stem cells (BMSC) 2005-2019. (3) 124 patients transplanted with PBSC and ATG (PBSC + ATG) 2014-2019. Three years survival was similar in the groups, 61% following allografting with PBSC, 54% with BMSC, and 59% with PBSC + ATG. Acute GvHD grade III-IV was 14%, 14%, and 7%; chronic GvHD was 81%, 32, and 26%; and extensive cGvHD 44%, 15%, and 6% in the corresponding groups. Both acute and chronic GvHD were significantly reduced in the PBSC + ATG-versus the PBSC group (p < 0.05 and p < 0.001 respectively).Transplant-related mortality (TRM) was 33%, 25%, and 17% (p = 0.18). Graft versus host disease and relapse free survival (GRFS) at 3 years was 43 %, 43%, and 64% in the groups. Adding ATG to the GvHD prophylaxis regimen of MUD allo-HSCT with PBSC resulted in a substantial reduction of both acute and chronic GvHD without compromising the disease control, reflected in a superior 3 years GRFS.
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Affiliation(s)
- M M Ali
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway.
| | - B Grønvold
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - M Remberger
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - I W Abrahamsen
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - A E Myhre
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Y Fløisand
- Centre for Cancer Cell Reprogramming, Institute of Clinical Medicine, University of Oslo, Oslo, Norway; The Clatterbridge Cancer Center NHS Foundation Trust, Liverpool, United Kingdom
| | - T Gedde-Dahl
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
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115
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Butera S, Cerrano M, Brunello L, Dellacasa CM, Faraci DG, Vassallo S, Mordini N, Sorasio R, Zallio F, Busca A, Bruno B, Giaccone L. Impact of anti-thymocyte globulin dose for graft-versus-host disease prophylaxis in allogeneic hematopoietic cell transplantation from matched unrelated donors: a multicenter experience. Ann Hematol 2021; 100:1837-1847. [PMID: 33948721 PMCID: PMC8195753 DOI: 10.1007/s00277-021-04521-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/08/2021] [Indexed: 01/07/2023]
Abstract
Despite the widespread use of rabbit anti-thymocyte globulin (ATG) to prevent acute and chronic graft-versus-host disease (aGVHD, cGVHD) after allogeneic hematopoietic cell transplantation (allo-HCT), convincing evidence about an optimal dose is lacking. We retrospectively evaluated the clinical impact of two different ATG doses (5 vs 6-7.5 mg/kg) in 395 adult patients undergoing HSCT from matched unrelated donors (MUD) at 3 Italian centers. Cumulative incidence of aGVHD and moderate-severe cGVHD did not differ in the 2 groups. We observed a trend toward prolonged overall survival (OS) and disease-free survival (DFS) with lower ATG dose (5-year OS and DFS 56.6% vs. 46.3%, p=0.052, and 46.8% vs. 38.6%, p=0.051, respectively) and no differences in relapse incidence and non-relapse mortality. However, a significantly increased infection-related mortality (IRM) was observed in patients who received a higher ATG dose (16.7% vs. 8.8% in the lower ATG group, p=0.019). Besides, graft and relapse-free survival (GRFS) was superior in the lower ATG group (5-year GRFS 43.1% vs. 32.4%, p=0.014). The negative impact of higher ATG dose on IRM and GRFS was confirmed by multivariate analysis. Our results suggest that ATG doses higher than 5 mg/kg are not required for MUD allo-HCT and seem associated with worse outcomes.
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Affiliation(s)
- Sara Butera
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Torino, Italy
| | - Marco Cerrano
- Department of Oncology, Division of Hematology, A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy
| | - Lucia Brunello
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy
- Department of Hematology, A.O. Santissimi Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Chiara Maria Dellacasa
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy
| | - Danilo Giuseppe Faraci
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Torino, Italy
| | - Sara Vassallo
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Torino, Italy
| | - Nicola Mordini
- Division of Hematology, A.O. Santi Croce e Carle, Cuneo, Italy
| | - Roberto Sorasio
- Division of Hematology, A.O. Santi Croce e Carle, Cuneo, Italy
| | - Francesco Zallio
- Department of Hematology, A.O. Santissimi Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Alessandro Busca
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy
| | - Benedetto Bruno
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Torino, Italy
| | - Luisa Giaccone
- Department of Oncology, SSD Trapianto Allogenico di Cellule Staminali, A.O.U. Città della Salute e della Scienza di Torino, Via Genova 3, 10126, Torino, Italy.
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Torino, Italy.
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Scheinberg P. Acquired severe aplastic anaemia: how medical therapy evolved in the 20th and 21st centuries. Br J Haematol 2021; 194:954-969. [PMID: 33855695 DOI: 10.1111/bjh.17403] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
The progress in aplastic anaemia (AA) management is one of success. Once an obscure entity resulting in death in most affected can now be successfully treated with either haematopoietic stem cell transplantation (HSCT) or immunosuppressive therapy (IST). The mechanisms that underly the diminution of haematopoietic stem cells (HSCs) are now better elucidated, and include genetics and immunological alterations. Advances in supportive care with better antimicrobials, safer blood products and iron chelation have greatly impacted AA outcomes. Working somewhat 'mysteriously', anti-thymocyte globulin (ATG) forms the base for both HSCT and IST protocols. Efforts to augment immunosuppression potency have not, unfortunately, led to better outcomes. Stimulating HSCs, an often-sought approach, has not been effective historically. The thrombopoietin receptor agonists (Tpo-RA) have been effective in stimulating early HSCs in AA despite the high endogenous Tpo levels. Dosing, timing and best combinations with Tpo-RAs are being defined to improve HSCs expansion in AA with minimal added toxicity. The more comprehensive access and advances in HSCT and IST protocols are likely to benefit AA patients worldwide. The focus of this review will be on the medical treatment advances in AA.
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Affiliation(s)
- Phillip Scheinberg
- Division of Haematology, Hospital A Beneficência Portuguesa, São Paulo, Brazil
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117
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Chu WS, Ng J. Immunomodulation in Administration of rAAV: Preclinical and Clinical Adjuvant Pharmacotherapies. Front Immunol 2021; 12:658038. [PMID: 33868303 PMCID: PMC8049138 DOI: 10.3389/fimmu.2021.658038] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/05/2021] [Indexed: 12/26/2022] Open
Abstract
Recombinant adeno-associated virus (rAAV) has attracted a significant research focus for delivering genetic therapies to target cells. This non-enveloped virus has been trialed in many clinical-stage therapeutic strategies but important obstacle in clinical translation is the activation of both innate and adaptive immune response to the protein capsid, vector genome and transgene product. In addition, the normal population has pre-existing neutralizing antibodies against wild-type AAV, and cross-reactivity is observed between different rAAV serotypes. While extent of response can be influenced by dosing, administration route and target organ(s), these pose concerns over reduction or complete loss of efficacy, options for re-administration, and other unwanted immunological sequalae such as local tissue damage. To reduce said immunological risks, patients are excluded if they harbor anti-AAV antibodies or have received gene therapy previously. Studies have incorporated immunomodulating or suppressive regimens to block cellular and humoral immune responses such as systemic corticosteroids pre- and post-administration of Luxturna® and Zolgensma®, the two rAAV products with licensed regulatory approval in Europe and the United States. In this review, we will introduce the current pharmacological strategies to immunosuppress or immunomodulate the host immune response to rAAV gene therapy.
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Affiliation(s)
- Wing Sum Chu
- Pharmacy Department, The Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Joanne Ng
- Gene Transfer Technology Group, Department of Maternal and Fetal Medicine, EGA Institute for Women's Health, University College London, London, United Kingdom
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118
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Outcomes Following ATG Therapy for Chronic Lung Allograft Dysfunction. Transplant Direct 2021; 7:e681. [PMID: 33748410 PMCID: PMC7969305 DOI: 10.1097/txd.0000000000001134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/08/2020] [Accepted: 12/29/2020] [Indexed: 12/19/2022] Open
Abstract
Chronic lung allograft dysfunction (CLAD) is the major factor limiting survival post lung transplantation (LTx) with limited effective therapeutic options. We report our 12-y experience of antithymocyte globulin (ATG) as second-line CLAD therapy.
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119
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Cevaal PM, Ali A, Czuba-Wojnilowicz E, Symons J, Lewin SR, Cortez-Jugo C, Caruso F. In Vivo T Cell-Targeting Nanoparticle Drug Delivery Systems: Considerations for Rational Design. ACS NANO 2021; 15:3736-3753. [PMID: 33600163 DOI: 10.1021/acsnano.0c09514] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
T cells play an important role in immunity and repair and are implicated in diseases, including blood cancers, viral infections, and inflammation, making them attractive targets for the treatment and prevention of diseases. Over recent years, the advent of nanomedicine has shown an increase in studies that use nanoparticles as carriers to deliver therapeutic cargo to T cells for ex vivo and in vivo applications. Nanoparticle-based delivery has several advantages, including the ability to load and protect a variety of drugs, control drug release, improve drug pharmacokinetics and biodistribution, and site- or cell-specific targeting. However, the delivery of nanoparticles to T cells remains a major technological challenge, which is primarily due to the nonphagocytic nature of T cells. In this review, we discuss the physiological barriers to effective T cell targeting and describe the different approaches used to deliver cargo-loaded nanoparticles to T cells for the treatment of disease such as T cell lymphoma and human immunodeficiency virus (HIV). In particular, engineering strategies that aim to improve nanoparticle internalization by T cells, including ligand-based targeting, will be highlighted. These nanoparticle engineering approaches are expected to inspire the development of effective nanomaterials that can target or manipulate the function of T cells for the treatment of T cell-related diseases.
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Affiliation(s)
| | | | - Ewa Czuba-Wojnilowicz
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, and the Department of Chemical Engineering, The University of Melbourne, Parkville, Victoria 3010, Australia
| | | | - Sharon R Lewin
- Victorian Infectious Diseases, Royal Melbourne Hospital at The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria 3004, Australia
| | - Christina Cortez-Jugo
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, and the Department of Chemical Engineering, The University of Melbourne, Parkville, Victoria 3010, Australia
| | - Frank Caruso
- ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, and the Department of Chemical Engineering, The University of Melbourne, Parkville, Victoria 3010, Australia
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Factors Associated with Post-Transplant Active Epstein-Barr Virus Infection and Lymphoproliferative Disease in Hematopoietic Stem Cell Transplant Recipients: A Systematic Review and Meta-Analysis. Vaccines (Basel) 2021; 9:vaccines9030288. [PMID: 33808928 PMCID: PMC8003684 DOI: 10.3390/vaccines9030288] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 12/29/2022] Open
Abstract
This systematic review was undertaken to identify risk factors associated with post-transplant Epstein–Barr virus (EBV) active infection and post-transplant lymphoproliferative disease (PTLD) in pediatric and adult recipients of hematopoietic stem cell transplants (HSCT). A literature search was conducted in PubMed and EMBASE to identify studies published until 30 June 2020. Descriptive information was extracted for each individual study, and data were compiled for individual risk factors, including, when possible, relative risks with 95% confidence intervals and/or p-values. Meta-analyses were planned when possible. The methodological quality and potential for bias of included studies were also evaluated. Of the 3362 titles retrieved, 77 were included (62 for EBV infection and 22 for PTLD). The overall quality of the studies was strong. Several risk factors were explored in these studies, but few statistically significant associations were identified. The use of anti-thymocyte globulin (ATG) was identified as the most important risk factor positively associated with post-transplant active EBV infection and with PTLD. The pooled relative risks obtained using the random-effect model were 5.26 (95% CI: 2.92–9.45) and 4.17 (95% CI: 2.61–6.68) for the association between ATG and post-transplant EBV infection and PTLD, respectively. Other risk factors for EBV and PTLD were found in the included studies, such as graft-versus-host disease, type of conditioning regimen or type of donor, but results are conflicting. In conclusion, the results of this systematic review indicate that ATG increases the risk of EBV infection and PTLD, but the link with all other factors is either nonexistent or much less convincing.
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121
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Tan X, Feng H, Guo Z, Wang L, Fu C, Sun L, Li Y, Xia Q, Hou L, Liu C, Zhu L, Chen G. Rabbit antithymocyte globulin induces human lymphocyte activation, proliferation, and apoptosis in the absence of complement: an experimental study. Transpl Int 2021; 34:930-941. [PMID: 33725365 DOI: 10.1111/tri.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 11/29/2022]
Abstract
Rabbit antithymocyte globulin (rATG) has become the first choice for induction therapy in HLA-presensitized patients undergoing organ transplantation. Meanwhile, complement inhibitors have been approved for preventing or treating antibody-mediated rejection in these patients. The biological effects of rATG on lymphocytes in cases of complement deficiency or significant inhibition are not yet clear. We measured lymphocyte activation, proliferation, and apoptosis in response to rATG treatment in the absence of complement. T-cell subsets were analyzed transcriptomically features to rATG stimulation. Activation-related phenotypes on T cells were determined in patients after rATG administration. We found that rATG treatment led to lymphocyte activation and proliferation in vitro without the addition of complement. A dose-dependent apoptosis in rATG-treated lymphocytes was detected, which was partially caspase-3-dependent but Fas/FasL-independent. T cells were more sensitive to rATG stimulation than were non-T cells. Both CD4+ T cells and CD8+ T cells upregulated a series of genes related to cell activation, cytokine production and apoptosis to rATG stimulation. CD69 and CD25 levels in surviving T cells were increased in patients after rATG administration. These findings indicate that rATG can stimulate lymphocyte activation, proliferation, and apoptosis in the absence of complement. Biologic effects of rATG other than complement-dependent cytotoxicity need to be concerned.
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Affiliation(s)
- Xiaosheng Tan
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Hao Feng
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiliang Guo
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lu Wang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Cheng Fu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingjuan Sun
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yakun Li
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiangbing Xia
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Hou
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | | | - Lan Zhu
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
| | - Gang Chen
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Organ Transplantation, Ministry of Education, Wuhan, China.,NHC Key Laboratory of Organ Transplantation, Wuhan, China.,Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China
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122
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Kyriakidis I, Vasileiou E, Rossig C, Roilides E, Groll AH, Tragiannidis A. Invasive Fungal Diseases in Children with Hematological Malignancies Treated with Therapies That Target Cell Surface Antigens: Monoclonal Antibodies, Immune Checkpoint Inhibitors and CAR T-Cell Therapies. J Fungi (Basel) 2021; 7:186. [PMID: 33807678 PMCID: PMC7999508 DOI: 10.3390/jof7030186] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Since 1985 when the first agent targeting antigens on the surface of lymphocytes was approved (muromonab-CD3), a multitude of such therapies have been used in children with hematologic malignancies. A detailed literature review until January 2021 was conducted regarding pediatric patient populations treated with agents that target CD2 (alefacept), CD3 (bispecific T-cell engager [BiTE] blinatumomab), CD19 (denintuzumab mafodotin, B43, BiTEs blinatumomab and DT2219ARL, the immunotoxin combotox, and chimeric antigen receptor [CAR] T-cell therapies tisagenlecleucel and axicabtagene ciloleucel), CD20 (rituximab and biosimilars, 90Y-ibritumomab tiuxetan, ofatumumab, and obinutuzumab), CD22 (epratuzumab, inotuzumab ozogamicin, moxetumomab pasudotox, BiTE DT2219ARL, and the immunotoxin combotox), CD25 (basiliximab and inolimomab), CD30 (brentuximab vedotin and iratumumab), CD33 (gemtuzumab ozogamicin), CD38 (daratumumab and isatuximab), CD52 (alemtuzumab), CD66b (90Y-labelled BW 250/183), CD248 (ontuxizumab) and immune checkpoint inhibitors against CTLA-4 (CD152; abatacept, ipilimumab and tremelimumab) or with PD-1/PD-L1 blockade (CD279/CD274; atezolizumab, avelumab, camrelizumab, durvalumab, nivolumab and pembrolizumab). The aim of this narrative review is to describe treatment-related invasive fungal diseases (IFDs) of each category of agents. IFDs are very common in patients under blinatumomab, inotuzumab ozogamicin, basiliximab, gemtuzumab ozogamicin, alemtuzumab, and tisagenlecleucel and uncommon in patients treated with moxetumomab pasudotox, brentuximab vedotin, abatacept, ipilimumab, pembrolizumab and avelumab. Although this new era of precision medicine shows promising outcomes of targeted therapies in children with leukemia or lymphoma, the results of this review stress the necessity for ongoing surveillance and suggest the need for antifungal prophylaxis in cases where IFDs are very common complications.
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Affiliation(s)
- Ioannis Kyriakidis
- Pediatric and Adolescent Hematology-Oncology Unit, 2nd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece; (I.K.); (E.V.)
| | - Eleni Vasileiou
- Pediatric and Adolescent Hematology-Oncology Unit, 2nd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece; (I.K.); (E.V.)
| | - Claudia Rossig
- Department of Pediatric Hematology and Oncology, University Children’s Hospital Münster, D-48149 Münster, Germany;
| | - Emmanuel Roilides
- Infectious Diseases Unit, Basic and Translational Research Unit, Special Unit for Biomedical Research and Education, 3rd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Hippokration General Hospital, 54642 Thessaloniki, Greece;
| | - Andreas H. Groll
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children’s Hospital Münster, D-48149 Münster, Germany;
| | - Athanasios Tragiannidis
- Pediatric and Adolescent Hematology-Oncology Unit, 2nd Department of Pediatrics, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, AHEPA Hospital, 54636 Thessaloniki, Greece; (I.K.); (E.V.)
- Center for Bone Marrow Transplantation and Department of Pediatric Hematology and Oncology, Infectious Disease Research Program, University Children’s Hospital Münster, D-48149 Münster, Germany;
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123
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Kroemer A, Belyayev L, Khan K, Loh K, Kang J, Duttargi A, Dhani H, Sadat M, Aguirre O, Gusev Y, Bhuvaneshwar K, Kallakury B, Cosentino C, Houlihan B, Diaz J, Moturi S, Yazigi N, Kaufman S, Subramanian S, Hawksworth J, Girlanda R, Robson SC, Matsumoto CS, Zasloff M, Fishbein TM. Rejection of intestinal allotransplants is driven by memory T helper type 17 immunity and responds to infliximab. Am J Transplant 2021; 21:1238-1254. [PMID: 32882110 PMCID: PMC8049508 DOI: 10.1111/ajt.16283] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 02/06/2023]
Abstract
Intestinal transplantation (ITx) can be life-saving for patients with advanced intestinal failure experiencing complications of parenteral nutrition. New surgical techniques and conventional immunosuppression have enabled some success, but outcomes post-ITx remain disappointing. Refractory cellular immune responses, immunosuppression-linked infections, and posttransplant malignancies have precluded widespread ITx application. To shed light on the dynamics of ITx allograft rejection and treatment resistance, peripheral blood samples and intestinal allograft biopsies from 51 ITx patients with severe rejection, alongside 37 stable controls, were analyzed using immunohistochemistry, polychromatic flow cytometry, and reverse transcription-PCR. Our findings inform both immunomonitoring and treatment. In terms of immunomonitoring, we found that while ITx rejection is associated with proinflammatory and activated effector memory T cells in the blood, evidence of treatment efficacy can only be found in the allograft itself, meaning that blood-based monitoring may be insufficient. In terms of treatment, we found that the prominence of intra-graft memory TNF-α and IL-17 double-positive T helper type 17 (Th17) cells is a leading feature of refractory rejection. Anti-TNF-α therapies appear to provide novel and safer treatment strategies for refractory ITx rejection; with responses in 14 of 14 patients. Clinical protocols targeting TNF-α, IL-17, and Th17 warrant further testing.
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Affiliation(s)
- Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Leonid Belyayev
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Katrina Loh
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Gastroenterology, Hepatology and Nutrition, Children’s National Medical Center, Washington, DC
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Anju Duttargi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Harmeet Dhani
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Mohammed Sadat
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Oswaldo Aguirre
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Yuriy Gusev
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, Washington, DC
| | - Krithika Bhuvaneshwar
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, Washington, DC
| | - Bhaskar Kallakury
- Department of Pathology, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher Cosentino
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Brenna Houlihan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Jamie Diaz
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Sangeetha Moturi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Nada Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Stuart Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Raffaele Girlanda
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Simon C. Robson
- Departments of Anesthesiology and Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Michael Zasloff
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
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124
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Hill GR, Betts BC, Tkachev V, Kean LS, Blazar BR. Current Concepts and Advances in Graft-Versus-Host Disease Immunology. Annu Rev Immunol 2021; 39:19-49. [PMID: 33428454 DOI: 10.1146/annurev-immunol-102119-073227] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Worldwide, each year over 30,000 patients undergo an allogeneic hema-topoietic stem cell transplantation with the intent to cure high-risk hematologic malignancy, immunodeficiency, metabolic disease, or a life-threatening bone marrow failure syndrome. Despite substantial advances in donor selection and conditioning regimens and greater availability of allograft sources, transplant recipients still endure the morbidity and mortality of graft-versus-host disease (GVHD). Herein, we identify key aspects of acute and chronic GVHD pathophysiology, including host/donor cell effectors, gut dysbiosis, immune system and cytokine imbalance, and the interface between inflammation and tissue fibrosis. In particular, we also summarize the translational application of this heightened understanding of immune dysregulation in the design of novel therapies to prevent and treat GVHD.
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Affiliation(s)
- Geoffrey R Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109, USA; .,Division of Medical Oncology University of Washington, Seattle, Washington 98109, USA
| | - Brian C Betts
- Division of Hematology, Oncology, and Blood and Marrow Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota 55455, USA
| | - Victor Tkachev
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA 02115, USA; , .,Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA 02215, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Leslie S Kean
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, MA 02115, USA; , .,Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA 02215, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota 55455, USA;
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125
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Keogh SJ, Dalle JH, Admiraal R, Pulsipher MA. Serotherapy as Graft-Versus-Host Disease Prophylaxis in Haematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:805189. [PMID: 35071142 PMCID: PMC8771860 DOI: 10.3389/fped.2021.805189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/01/2021] [Indexed: 12/26/2022] Open
Abstract
Serotherapy comprising agents such as anti-thymocyte globulin, anti-T-lymphocyte globulin, and the anti-CD52 monoclonal antibody alemtuzumab is used widely to reduce the incidence of graft-versus-host disease (GvHD) after paediatric haematopoietic stem cell transplantation (HSCT). The outcome of transplants using matched unrelated donors now approaches that of matched sibling donors. This is likely due to better disease control in recipients, the use of donors more closely human-leukocyte antigen (HLA)-matched to recipients, and more effective graft-versus-host disease (GvHD) prophylaxis. The price paid for reduced GvHD is slower immune reconstitution of T cells and thus more infections. This has led to studies looking to optimise the amount of serotherapy used. The balance between prevention of GvHD on one side and prevention of infections and relapse on the other side is quite delicate. Serotherapy is given with chemotherapy-/radiotherapy-based conditioning prior to HSCT. Due to their long half-lives, agents used for serotherapy may be detectable in patients well after graft infusion. This exposes the graft-infused T cells to a lympholytic effect, impacting T-cell recovery. As such, excessive serotherapy dosing may lead to no GvHD but a higher incidence of infections and relapse of leukaemia, while under-dosing may result in a higher chance of serious GvHD as immunity recovers more quickly. Individualised dosing is being developed through studies including retrospective analyses of serotherapy exposure, population pharmacokinetic modelling, therapeutic drug monitoring in certain centres, and the development of dosing models reliant on factors including the patient's peripheral blood lymphocyte count. Early results of "optimal" dosing strategies for serotherapy and conditioning chemotherapy show promise of improved overall survival.
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Affiliation(s)
- Steven J Keogh
- Cancer Centre for Children, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Jean-Hugues Dalle
- Hôpital Robert Debré, GHU AP-HP. Nord Université de Paris, Paris, France
| | - Rick Admiraal
- Princess Maxima Center for Pediatric Oncology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Michael A Pulsipher
- Children's Hospital Los Angeles, Cancer and Blood Disease Institute, Los Angeles, CA, United States
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126
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Cho B, Min G, Park S, Park S, Shin S, Yahng S, Jeon Y, Yoon J, Lee S, Eom K, Kim Y, Lee S, Min C, Cho S, Kim D, Lee JW, Kim M, Kim Y, Kim H. Haploidentical vs matched unrelated donor transplantation for acute myeloid leukemia in remission: A prospective comparative study. Am J Hematol 2021; 96:98-109. [PMID: 32905642 DOI: 10.1002/ajh.25993] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 01/17/2023]
Abstract
Despite comparable outcomes of haploidentical transplants (Haplo-HSCT) with HLA-matched unrelated transplants (MUD-HSCT) in retrospective comparisons, few studies have prospectively compared Haplo-HSCT with MUD-HSCT in AML. Here, we prospectively compared the outcomes of Haplo-HSCT with MUD-HSCT for AML in remission (n = 110) to prove non-inferiority of overall survival in Haplo-HSCT. Both groups were well balanced in factors related to biological features of AML and measurable residual disease (MRD) status by Wilms' tumor gene 1 (WT1) assay. A unique, reduced-toxicity preparative regimen was used for Haplo-HSCT, whereas mostly-myeloablative regimen was for MUD-HSCT. Both groups showed similar patterns of neutrophil and platelet recovery, whereas delayed T-cell reconstitution in Haplo-HSCT was found compared with MUD-HSCT. No significant differences were found in acute or chronic graft-vs-host-disease (GVHD) and post-transplant infectious events with an exception of EBV or CMV infection, which occurred more frequently in Haplo-HSCT. After a median follow-up of 47 months, no significant differences in overall survival (65% vs 54%, P = .146), disease-free survival (67% vs 53%, P = .142), relapse (20% vs 21%, P = .858), non-relapse mortality (14% vs 26%, P = .103), or GVHD-free/relapse-free survival (54% vs 41%, P = .138) were observed for Haplo-HSCT vs MUD-HSCT. In multivariate analysis, WT1 expression before transplantation independently predicted relapse, resulting in inferior survival. Separate analysis of unenrolled patients (n = 110) who were excluded or refused to participate in this study showed consistent results with enrolled patients. This prospective study demonstrated the non-inferiority of Haplo-HSCT to MUD-HSCT for AML in remission, and validated the role of WT1 quantification as an MRD marker (ClinicalTrial.gov identifier: NCT01751997).
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Affiliation(s)
- Byung‐Sik Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Gi‐June Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Silvia Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Sung‐Soo Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Seung‐Hwan Shin
- Department of Hematology, Eunpyeong St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Seung‐Ah Yahng
- Department of Hematology, Incheon St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Young‐Woo Jeon
- Department of Hematology, Yeouido St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Jae‐Ho Yoon
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Sung‐Eun Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Ki‐Seong Eom
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Yoo‐Jin Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Chang‐Ki Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Seok‐Goo Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Dong‐Wook Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Hee‐Je Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Leukemia Research Institute, College of Medicine The Catholic University of Korea Seoul Republic of Korea
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127
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Jo S, Fang S. Therapeutic Strategies for Diabetes: Immune Modulation in Pancreatic β Cells. Front Endocrinol (Lausanne) 2021; 12:716692. [PMID: 34484126 PMCID: PMC8415970 DOI: 10.3389/fendo.2021.716692] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 07/30/2021] [Indexed: 12/14/2022] Open
Abstract
Increased incidence of type I and type II diabetes has been prevailed worldwide. Though the pathogenesis of molecular mechanisms remains still unclear, there are solid evidence that disturbed immune homeostasis leads to pancreatic β cell failure. Currently, autoimmunity and uncontrolled inflammatory signaling pathways have been considered the major factors in the pathogenesis of diabetes. Many components of immune system have been reported to implicate pancreatic β cell failure, including helper T cells, cytotoxic T cells, regulatory T cells and gut microbiota. Immune modulation of those components using small molecules and antibodies, and fecal microbiota transplantation are undergoing in many clinical trials for the treatment of type I and type II diabetes. In this review we will discuss the basis of molecular pathogenesis focusing on the disturbed immune homeostasis in type I and type II diabetes, leading to pancreatic β cell destruction. Finally, we will introduce current therapeutic strategies and clinical trials by modulation of immune system for the treatment of type I and type II diabetes patients.
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Affiliation(s)
- Sugyeong Jo
- Department of Medical Science, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, South Korea
| | - Sungsoon Fang
- Department of Medical Science, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, South Korea
- Severance Biomedical Science Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
- *Correspondence: Sungsoon Fang,
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Vaidya GN, Czer LSC, Luthringer D, Kittleson M, Patel J, Chang DH, Kransdorf E, Geft D, Azarbal B, Hamilton M, Kobashigawa J. Heart Transplantation for Giant Cell Myocarditis: A Case Series. Transplant Proc 2020; 53:348-352. [PMID: 33384178 DOI: 10.1016/j.transproceed.2020.10.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/13/2020] [Accepted: 10/30/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Giant cell myocarditis (GCM) has a poor prognosis without heart transplant, but post-transplant survival is unknown. PURPOSE To describe the post-transplant survival of patients with GCM at a large transplant center. METHODS Seven patients underwent heart transplant for histologically confirmed GCM of the explanted heart. The median age was 59 years, and 43% (3 of 7) were female. All patients had cardiogenic shock, multiorgan failure, elevated troponin, and recurrent ventricular tachycardia, and some required mechanical circulatory support. All patients received rabbit antithymocyte globulin (rATG) in the perioperative period at a dose of 1.5 mg/kg daily for 1 to 5 days and 4 received intravenous immunoglobulin 1 g/kg daily for 2 days after rATG. All patients had early initiation of tacrolimus by first to third postoperative day depending on renal function, early mycophenolate, and high dose steroid. All were maintained using tacrolimus, mycophenolate, and prednisone. RESULTS One patient had asymptomatic recurrence of GCM at 3 months, managed by up-titration of tacrolimus, and had asymptomatic 2R cellular rejection at 4 months, managed with steroid bolus. No patient had high-grade rejection. One patient died at 267 days, possibly of GCM. Six of 7 (86%) remain alive at a median of 842 days (2.3 years) post transplant. CONCLUSIONS Patients with GCM have excellent post-transplant survival with use of rATG and triple drug immunosuppressive therapy; however, some patients remain at risk for GCM recurrence after transplant, which may respond to augmented immunosuppression.
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Affiliation(s)
- Gaurang Nandkishor Vaidya
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Lawrence S C Czer
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California.
| | - Daniel Luthringer
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michelle Kittleson
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Jignesh Patel
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - David H Chang
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Evan Kransdorf
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Dael Geft
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Babak Azarbal
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Michele Hamilton
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
| | - Jon Kobashigawa
- Advanced Heart Disease and Heart Transplant Programs, Cedars-Sinai Smidt Heart Institute, Los Angeles, California
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129
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Martinez-Cibrian N, Zeiser R, Perez-Simon JA. Graft-versus-host disease prophylaxis: Pathophysiology-based review on current approaches and future directions. Blood Rev 2020; 48:100792. [PMID: 33386151 DOI: 10.1016/j.blre.2020.100792] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/11/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Graft-versus-host disease (GvHD) was first described in 1959, since then major efforts have been made in order to understand its physiopathology and animal models have played a key role. Three steps, involving different pathways, have been recognised in either acute and chronic GvHD, identifying them as two distinct entities. In order to reduce GvHD incidence and severity, prophylactic measures were added to transplant protocols. The combination of a calcineurin inhibitor (CNI) plus an antimetabolite remains the standard of care. Better knowledge of GvHD pathophysiology has moved this field forward and nowadays different drugs are being used on a daily basis. Improving GvHD prophylaxis is a major goal as it would translate into less non-relapse mortality and better overall survival. As compared to CNI plus methotrexate the combination of CNI plus mycophenolate mophetil (MMF) allows us to obtain similar results in terms of GvHD incidence but a lower toxicity rate in terms of neutropenia or mucositis. The use of ATG has been related to a lower risk of acute and chronic GvHD in prospective randomized trials as well as the use of posttransplant Cyclophosphamide, with no or marginal impact on overall survival but with an improvement in GvHD-relapse free survival (GRFS). The use of sirolimus has been related to a lower risk of acute GvHD and significantly influenced overall survival in one prospective randomized trial. Other prospective trials have evaluated the use of receptors such as CCR5 or α4β7 to avoid T-cells trafficking into GvHD target organs, cytokine blockers or immune check point agonists. Also, epigenetic modifiers have shown promising results in phase II trials. Attention should be paid to graft-versus-leukemia, infections and immune recovery before bringing new prophylactic strategies to clinical practice. Although the list of novel agents for GvHD prophylaxis is growing, randomized trials are still lacking for many of them.
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Affiliation(s)
- Nuria Martinez-Cibrian
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain
| | - Robert Zeiser
- Department of Hematology, Oncology, and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Jose A Perez-Simon
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain.
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130
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Efficacy of low dose antithymocyte globulin on overall survival, relapse rate, and infectious complications following allogeneic peripheral blood stem cell transplantation for leukemia in children. Bone Marrow Transplant 2020; 56:890-899. [PMID: 33199818 DOI: 10.1038/s41409-020-01121-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/09/2020] [Accepted: 10/28/2020] [Indexed: 11/08/2022]
Abstract
Antithymocyte globulin (ATG) and anti-T lymphocyte globulin (ATLG) have been widely used to prevent graft-versus-host disease (GvHD), each with distinct properties and noninterchangeable doses. However, the optimal dose of ATG in children undergoing allo-PBSCT for leukemia has not yet been established. Therefore, the impact of ATG dose on overall survival (OS), relapse, GvHD, and infectious complications was investigated. Patients administered high dose (unrelated: 7.5 mg/kg, haploidentical: 10.0 mg/kg) and low dose (unrelated: 3.75 mg/kg, haploidentical: 5.0 mg/kg) ATG during two consecutive time periods were compared. There were 78 (39.8%) patients in the low dose group and 118 (60.2%) in the high dose group. OS was superior in the low dose group compared to the high dose group (P = 0.017), and relapse incidence was significantly lower in the low dose group (P = 0.022). Cumulative incidences of acute and chronic GvHD were similar between the groups (P = 0.095 and P = 0.672, respectively). Cytomegalovirus reactivation (70.3% vs. 51.3%, P = 0.007), Epstein-Barr virus reactivation (81.4% vs. 39.7%, P < 0.001), and invasive bacterial infections (12.7% vs. 0%, P = 0.001) post transplant were more frequent in the high dose group compared to the low dose group. Therefore, low dose ATG is more optimal in pediatric allo-PBSCT providing better OS while lowering the risk of relapse and infectious complications.
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131
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Binder C, Sellberg F, Cvetkovski F, Berglund E, Berglund D. Siplizumab, an Anti-CD2 Monoclonal Antibody, Induces a Unique Set of Immune Modulatory Effects Compared to Alemtuzumab and Rabbit Anti-Thymocyte Globulin In Vitro. Front Immunol 2020; 11:592553. [PMID: 33262770 PMCID: PMC7686512 DOI: 10.3389/fimmu.2020.592553] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/14/2020] [Indexed: 01/09/2023] Open
Abstract
Antibodies are commonly used in organ transplant induction therapy and to treat autoimmune disorders. The effects of some biologics on the human immune system remain incompletely characterized and a deeper understanding of their mechanisms of action may provide useful insights for their clinical application. The goal of this study was to contrast the mechanistic properties of siplizumab with Alemtuzumab and rabbit Anti-Thymocyte Globulin (rATG). Mechanistic assay systems investigating antibody-dependent cell-mediated cytotoxicity, antibody-dependent cell phagocytosis and complement-dependent cytotoxicity were used to characterize siplizumab. Further, functional effects of siplizumab, Alemtuzumab, and rATG were investigated in allogeneic mixed lymphocyte reaction. Changes in T cell activation, T cell proliferation and frequency of naïve T cells, memory T cells and regulatory T cells induced by siplizumab, Alemtuzumab and rATG in allogeneic mixed lymphocyte reaction were assessed via flow cytometry. Siplizumab depleted T cells, decreased T cell activation, inhibited T cell proliferation and enriched naïve and bona fide regulatory T cells. Neither Alemtuzumab nor rATG induced the same combination of functional effects. The results presented in this study should be used for further in vitro and in vivo investigations that guide the clinical use of immune modulatory biologics.
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Affiliation(s)
- Christian Binder
- Section of Clinical Immunology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Research and Development, ITB-Med AB, Stockholm, Sweden
| | - Felix Sellberg
- Section of Clinical Immunology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Research and Development, ITB-Med AB, Stockholm, Sweden
| | | | - Erik Berglund
- Research and Development, ITB-Med AB, Stockholm, Sweden.,Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Transplantation Surgery, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - David Berglund
- Section of Clinical Immunology, Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,Research and Development, ITB-Med AB, Stockholm, Sweden
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Post-transplant cyclophosphamide for GVHD prophylaxis compared to ATG-based prophylaxis in unrelated donor transplantation. Ann Hematol 2020; 100:541-553. [PMID: 33140137 DOI: 10.1007/s00277-020-04317-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/26/2020] [Indexed: 12/23/2022]
Abstract
Post-transplant cyclophosphamide (PTCY) effectively prevents graft-versus-host disease after unmanipulated HLA-haploidentical HSCT. The use of PTCY in the unrelated donor HSCT setting is less explored. We conducted a retrospective study of 132 consecutive patients undergoing a matched or 9/10 mismatched unrelated donor HSCT in 4 centers in Spain, 60 with anti-thymocyte globulin (ATG)-based prophylaxis combined with MTX-CsA, and 72 using a PTCY-based regimen. Peripheral blood stem cells were used as graft in most patients (111 patients, 84%); mMUD donors were balanced between groups. Cumulative incidences of grades II-IV and III-IV acute GVHD at 100 days were lower in the PTCy group (46% vs. 67%, p = 0.008; 3% vs. 34%, p = 0.003), without statistically significant differences in the 2-year cumulative incidence of chronic moderate-severe GVHD. At 2 years, no significant differences were observed in overall survival, event-free survival, cumulative incidence of relapse, and non-relapse mortality. GVHD was the most frequent cause of NRM in the ATG group. No differences were observed between groups in the composite endpoint of GVHD-free and relapse-free survival. In this study, PTCy combined with additional immunosuppression after MUD/mMUD HSCT showed a reduction of aGVHD rate with safety results comparable to those obtained with the ATG-based prophylaxis.
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Abstract
The clinical and laboratory features of COVID-19 are reviewed with attention to the immunologic manifestations of the disease. Recent COVID-19 publications describe a variety of clinical presentations including an asymptomatic state, pneumonia, a hemophagocytic lymphohistiocytosis like syndrome, Multisystem Inflammatory Syndrome in Children (MIS-C) but, also called Pediatric Inflammatory Multisystem Syndrome-Toxic Shock (PIMS-TS), Kawasaki Disease, and myocarditis. A common theme amongst multiple reports suggests an overexuberant autoimmune component of the disease but a common pathophysiology to explain the variations in clinical presentation has been elusive. Review of the basic science of other viral induced autoimmune disorders may give clues as to why immunosuppressive and immunomodulating regimens now appear to have some efficacy in COVID-19. Review of the immunopathology also reveals other therapies that have yet to be explored. There is potential use of T cell depleting therapies and possibly anti-CD20 therapy for COVID-19 and clinical research using these medications is warranted.
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134
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Tumour-reactive B cells and antibody responses after allogeneic haematopoietic cell transplantation. IMMUNO-ONCOLOGY TECHNOLOGY 2020; 7:15-22. [PMID: 35754458 PMCID: PMC9216635 DOI: 10.1016/j.iotech.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
For many high-risk haematologic malignancies, such as acute myeloid leukaemia, the success of therapy relies mainly on invoking a curative antitumour immune response. This can be achieved by inducing a graft-versus-leukaemia response following allogeneic haematopoietic cell transplantation. While the contribution of T cells and natural killer cells to graft-versus-leukaemia responses is established, the contribution of B cells and antibodies is relatively unexplored. This article reviews what is known about the contribution of B cells and tumour-specific antibody responses to a successful graft-versus-leukaemia response leading to eradication of the tumour.
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135
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Roberts MB, Fishman JA. Immunosuppressive Agents and Infectious Risk in Transplantation: Managing the "Net State of Immunosuppression". Clin Infect Dis 2020; 73:e1302-e1317. [PMID: 32803228 DOI: 10.1093/cid/ciaa1189] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Indexed: 12/14/2022] Open
Abstract
Successful solid organ transplantation reflects meticulous attention to the details of immunosuppression, balancing risks for graft rejection against risks for infection. The 'net state of immune suppression' is a conceptual framework of all factors contributing to infectious risk. Assays which measure immune function in the immunosuppressed transplant recipient relative to infectious risk and allograft function are lacking. The best measures of integrated immune function may be quantitative viral loads to assess the individual's ability to control latent viral infections. Few studies address adjustment of immunosuppression during active infections. Thus, confronted with infection in solid organ recipients, the management of immunosuppression is based largely on clinical experience. This review examines known measures of immune function and the immunologic effects of common immunosuppressive drugs and available studies reporting modification of drug regimens for specific infections. These data provide a conceptual framework for the management of immunosuppression during infection in organ recipients.
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Affiliation(s)
- Matthew B Roberts
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA
| | - Jay A Fishman
- Transplant Infectious Disease and Compromised Host Program and Transplant Center, Massachusetts General Hospital, Boston MA.,Harvard Medical School, Boston, MA
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136
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Huang J, Huang F, Fan Z, Xu N, Xuan L, Liu H, Shi P, Jiang L, Zhang Y, Sun J, Liu Q. Haploidentical related donor vs matched sibling donor allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia and myelodysplastic syndrome aged over 50 years: A single-center retrospective study. Cancer Med 2020; 9:6244-6255. [PMID: 32686915 PMCID: PMC7476836 DOI: 10.1002/cam4.3290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 12/12/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo‐HSCT) is a potentially curative therapeutic option for patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). Increasing data suggest that haploidentical donor (HID) transplantation achieve comparable outcomes with HLA‐matched sibling donor (MSD) in adult AML/MDS. This retrospective study compared the outcomes of AML or MDS patients age ≥50 years underwent HID and MSD transplantation. One hundred and fifty‐six patients were enrolled in this study, including 75 HID and 81 MSD transplantation. The 100‐day cumulative incidence of II‐IV° acute graft‐versus‐host disease (GVHD) was 33.3 ± 5.4% vs 22.2 ± 4.6%, respectively, in HID and MSD groups (P = .066), and III‐IV° acute GVHD was not significantly different between two groups (5.3%±2.6% vs 6.2%±2.7%, respectively, P = .823). The 2‐year cumulative incidence of limited and extensive chronic GVHD was not statistically different in HID and MSD groups (20.9 ± 5.5% vs 18.9 ± 4.8% and 13.0 ± 4.7% vs 19.7 ± 5.0%, P = .889 and P = .269, respectively). The 2‐year cumulative incidences of relapse (27.0 ± 5.6% vs 22.7 ± 5.1%, P = .509), 2‐year overall survival (63.0 ± 5.8% vs 66.7 ± 5.4%, P = .454), 2‐year transplant‐related mortality (17.2 ± 4.6% vs 17.4 ± 4.4%, P = .847), 2‐year progression‐free survival (59.3 ± 5.8% vs 64.5 ± 5.4%, P = .437), 2‐year GVHD‐free relapse‐free survival (42.6 ± 5.9% vs 40.9 ± 5.6%, P = .964) were not significantly different in the two groups. The present data showed equivalent outcomes in AML or MDS patients age ≥50 years underwent HID and MSD transplantation.
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Affiliation(s)
- Jiafu Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yu Zhang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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137
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Afzali S, Salehi S, Shahi A, Amirzargar A. B cell modulation strategies in the improvement of transplantation outcomes. Mol Immunol 2020; 125:140-150. [PMID: 32682148 DOI: 10.1016/j.molimm.2020.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/19/2020] [Accepted: 06/30/2020] [Indexed: 01/03/2023]
Abstract
Successful transplantation outcome is the final goal in most end stage and nonfunctional organs; however, despite using different therapeutic strategies, antibody-mediated rejection is still a big obstacle. B cells have a key role in transplant rejection by several functions, such as antibody production, antigen presenting, contribution in T cell activation, forming the germinal center, and tertiary lymphoid organs. Therefore, B cells modulation seems to be very crucial in transplant outcome. A double-edged sword function is considered for B cells during transplantation; On the one hand, antibody production against the transplanted organ induces antibody-mediated rejection. On the other hand, IL10 production by regulatory B (Breg) cells induces graft tolerance. Nowadays, several monoclonal antibodies (mAb) are available for B cell modulation that are routinely used in transplant recipients, among which rituximab (anti-CD20 mAb) act in eliminating B cells. However, there are some other monoclonal antibodies, such as epratuzumab and Inotuzumab ozogamicin (IO), which exert anti-CD22 activity, resulting in disruption of B cell functions and induction of tolerance in autoimmune disease or B cell malignancies; that notwithstanding, these mAbs have not yet been tried in transplantation. In this review, we focus on different methods for modulating the activity of B cells as well as induction of Breg cells, aiming to prevent the allograft rejection.
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Affiliation(s)
- Shima Afzali
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran; Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Salehi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Shahi
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Aliakbar Amirzargar
- Department of Immunology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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138
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Chang YJ, Wu DP, Lai YR, Liu QF, Sun YQ, Hu J, Hu Y, Zhou JF, Li J, Wang SQ, Li W, Du X, Lin DJ, Ren HY, Chen FP, Li YH, Zhang X, Huang H, Song YP, Jiang M, Hu JD, Liang YM, Wang JB, Xiao Y, Huang XJ. Antithymocyte Globulin for Matched Sibling Donor Transplantation in Patients With Hematologic Malignancies: A Multicenter, Open-Label, Randomized Controlled Study. J Clin Oncol 2020; 38:3367-3376. [PMID: 32650683 DOI: 10.1200/jco.20.00150] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE The role of antithymocyte globulin (ATG) in preventing acute graft-versus-host disease (aGVHD) after HLA-matched sibling donor transplantation (MSDT) is still controversial. PATIENTS AND METHODS We performed a prospective, multicenter, open-label, randomized controlled trial (RCT) across 23 transplantation centers in China. Patients ages 40-60 years with standard-risk hematologic malignancies with an HLA-matched sibling donor were randomly assigned to an ATG group (4.5 mg/kg thymoglobulin plus cyclosporine [CsA], methotrexate [MTX], and mycophenolate mofetil [MMF]) and a control group (CsA, MTX, and MMF). The primary end point of this study was grade 2-4 aGVHD on day 100. RESULTS From November 2013 to April 2018, 263 patients were enrolled. The cumulative incidence rate of grade 2-4 aGVHD was significantly reduced in the ATG group (13.7%; 95% CI, 13.5% to 13.9%) compared with the control group (27.0%; 95% CI, 26.7% to 27.3%; P = .007). The ATG group had significantly lower incidences of 2-year overall chronic GVHD (27.9% [95% CI, 27.6% to 28.2%] v 52.5% [95% CI, 52.1% to 52.9%]; P < .001) and 2-year extensive chronic GVHD (8.5% [95% CI, 8.4% to 8.6%] v 23.2% [95% CI, 22.9% to 23.5%]; P = .029) than the control group. There were no differences between the ATG and control groups with regard to cytomegalovirus reactivation, Epstein-Barr virus reactivation, 3-year nonrelapse mortality (NRM), 3-year cumulative incidence of relapse (CIR), 3-year overall survival, or 3-year leukemia-free survival. Three-year GVHD relapse-free survival was significantly improved in the ATG group (38.7%; 95% CI, 29.9% to 47.5%) compared with the control group (24.5%; 95% CI, 16.9% to 32.1%; P = .003). CONCLUSION Our study is the first prospective RCT in our knowledge to demonstrate that ATG can effectively decrease the incidence of aGVHD after MSDT in the CsA era without affecting the CIR or NRM.
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Affiliation(s)
- Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, and Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - De-Pei Wu
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yong-Rong Lai
- Department of Hematology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Qi-Fa Liu
- Nanfang Hospital Affiliated to Southern Medical University, Guangzhou, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, and Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Jiong Hu
- State Key Laboratory for Medical Genomics, Department of Hematology, Shanghai Institute of Hematology, and Collaborative Innovation Center of Hematology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Hu
- Union Hospital Affiliated With Huazhong University of Science and Technology, Wuhan, China
| | - Jian-Feng Zhou
- Department of Hematology, Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Juan Li
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shun-Qing Wang
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Wei Li
- The First Hospital of Jilin University, Changchun, China
| | - Xin Du
- Guangdong General Hospital, Guangzhou, China
| | - Dong-Jun Lin
- Third Hospital of Sun Yat-sen University, Guangzhou, China
| | - Han-Yun Ren
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Fang-Pin Chen
- Department of Hematology, Xiangya Hospital, Central South University, Changsha, China
| | - Yu-Hua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Xi Zhang
- Xinqiao Hospital Affiliated to Third Military Medical University, Chongqing, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Yong-Ping Song
- The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Ming Jiang
- The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Jian-Da Hu
- Fujian Medical University Union Hospital, Fuzhou, China
| | - Ying-Min Liang
- Tangdu Hospital Air Force Medical University, Xi'an, China
| | | | - Yang Xiao
- Southern Theater General Hospital of the Chinese People's Liberation Army, Guangzhou, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, and Peking-Tsinghua Center for Life Sciences, Beijing, China
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139
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Brissot E, Labopin M, Moiseev I, Cornelissen JJ, Meijer E, Van Gorkom G, Rovira M, Ciceri F, Griskevicius L, Blaise D, Forcade E, Mistrik M, Mielke S, Bulabois CE, Niittyvuopio R, Deconinck E, Ruggeri A, Sanz J, Spyridonidis A, Savani B, Giebel S, Nagler A, Mohty M. Post-transplant cyclophosphamide versus antithymocyte globulin in patients with acute myeloid leukemia in first complete remission undergoing allogeneic stem cell transplantation from 10/10 HLA-matched unrelated donors. J Hematol Oncol 2020; 13:87. [PMID: 32620146 PMCID: PMC7333262 DOI: 10.1186/s13045-020-00923-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Graft-versus-host disease (GVHD) remains a major contributor to mortality and morbidity after allogeneic stem-cell transplantation (allo-HSCT). The updated recommendations suggest that rabbit antithymocyte globulin or anti-T-lymphocyte globulin (ATG) should be used for GVHD prophylaxis in patients undergoing matched-unrelated donor (MUD) allo-HSCT. More recently, using post-transplant cyclophosphamide (PTCY) in the haploidentical setting has resulted in low incidences of both acute (aGVHD) and chronic GVHD (cGVHD). Therefore, the aim of our study was to compare GVHD prophylaxis using either PTCY or ATG in patients with acute myeloid leukemia (AML) who underwent allo-HSCT in first remission (CR1) from a 10/10 HLA-MUD. METHODS Overall, 174 and 1452 patients from the EBMT registry receiving PTCY and ATG were included. Cumulative incidence of aGVHD and cGVHD, leukemia-free survival, overall survival, non-relapse mortality, cumulative incidence of relapse, and refined GVHD-free, relapse-free survival were compared between the 2 groups. Propensity score matching was also performed in order to confirm the results of the main analysis RESULTS: No statistical difference between the PTCY and ATG groups was observed for the incidence of grade II-IV aGVHD. The same held true for the incidence of cGVHD and for extensive cGVHD. In univariate and multivariate analyses, no statistical differences were observed for all other transplant outcomes. These results were also confirmed using matched-pair analysis. CONCLUSION These results highlight that, in the10/10 HLA-MUD setting, the use of PTCY for GVHD prophylaxis may provide similar outcomes to those obtained with ATG in patients with AML in CR1.
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Affiliation(s)
- Eolia Brissot
- Sorbonne Université, AP-HP, INSERM UMRs938, Paris, France.
- Service d'Hématologie clinique et de Thérapie cellulaire, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184, rue du Faubourg Saint Antoine, 75012, Paris, France.
| | - Myriam Labopin
- European Society for Blood and Marrow Transplantation Paris Study Office/CEREST-TC, Paris, France
| | - Ian Moiseev
- R.M. Gorbacheva Memorial Institute of Oncology, Hematology and Transplantation, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russian Federation
| | - J J Cornelissen
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ellen Meijer
- Amsterdam University Medical Center, VU Medical Center, Department of Hematology, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Gwendolyn Van Gorkom
- Dept. Internal Medicine, Hematology/Oncology, University Hospital Maastricht, Maastricht, The Netherlands
| | - Montserrat Rovira
- Apheresis & Cellular Therapy Unit, Department of Hemotherapy and Hemostasis, ICMHO, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Laimonas Griskevicius
- Hematology, Oncology & Transfusion Center, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Didier Blaise
- Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | | | - Martin Mistrik
- Department of Haematology and Transfusion Medicine, University Hospital and Comenius University, Bratislava, Slovak Republic
| | - Stephan Mielke
- Department of Internal Medicine II, University Hospital of Würzburg, Oberdürrbacher Str. 6, D-97080, Würzburg, Germany
| | | | - Riitta Niittyvuopio
- HUCH Comprehensive Cancer Center, Stem Cell Transplantation Unit, Helsinki, Finland
| | - Eric Deconinck
- Service d'Hématologie, Hopital Jean Minjoz, Besançon, France
| | - Annalisa Ruggeri
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
- University Vita-Salute San Raffaele, Milan, Italy
| | - Jaime Sanz
- Department of Haematology, University Hospital La Fe, University of Valencia, Valencia, Spain
- Department of Haematology, Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Alexandros Spyridonidis
- Department of Internal Medicine, Bone Marrow Transplantation Unit, University Hospital of Patras, Patras, Greece
| | - Bipin Savani
- Long Term Transplant Clinic, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie Memorial Cencer Center and Institute of Oncology, Gliwice, Poland
| | - Arnon Nagler
- Hematology Division, BMT and Cord Blood Bank, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Mohamad Mohty
- Sorbonne Université, AP-HP, INSERM UMRs938, Paris, France
- Service d'Hématologie clinique et de Thérapie cellulaire, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 184, rue du Faubourg Saint Antoine, 75012, Paris, France
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140
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Pagliuca S, Prata PH, Xhaard A, Frieri C, Giannoni L, Sutra Del Galy A, Brignier A, Sicre de Fontbrune F, Michonneau D, Dhedin N, Peffault de Latour R, Socié G, Robin M. Long-term outcomes and risk factor analysis of steroid-refractory graft versus host disease after hematopoietic stem cell transplantation. Bone Marrow Transplant 2020; 56:38-49. [PMID: 32587336 DOI: 10.1038/s41409-020-0977-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/19/2020] [Accepted: 06/10/2020] [Indexed: 11/09/2022]
Abstract
Steroid-refractory graft versus host disease (GVHD) represents a fearsome complication after allogeneic hematopoietic stem cell transplantation (HSCT). We conducted a retrospective study on outcomes and risk factors associated with acute and chronic steroid-refractory GVHD in a large cohort of 1207 patients receiving HSCT in Saint Louis Hospital between 2007 and 2017. Among patients who developed an acute and/or a chronic GVHD, the cumulative incidences of acute and chronic steroid-refractory disease were 31% and 48%, respectively, at day +100 and 1-year post-HSCT. Through a multivariable analysis we selected several risk factors associated with the development of a steroid-refractory disease. For acute GVHD steroid refractoriness, we identified (1) a very high disease risk index, (2) an unrelated donor, (3) the absence of in vivo T-depletion as GVHD prophylaxis, and (4) a reduced intensity conditioning regimen. For chronic GVHD, (1) the use of peripheral blood stem cells, (2) unrelated donors, and (3) absence of in vivo T-depletion were more likely associated with a steroid-refractory disease. After the construction of a multistate dynamic model, we found that the probability of being alive without relapse after the resolution of all GVHD episodes was about 36% in the long term.
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Affiliation(s)
- Simona Pagliuca
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France. .,Université de Paris, Paris, France. .,Department of Translational Hematology and Oncology Research, Cleveland Clinic Foundation, Cleveland, Ohio, United States.
| | - Pedro Henrique Prata
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Aliénor Xhaard
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Camilla Frieri
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France.,Department of Hematology and Transplantation, Federico II University, Naples, Italy
| | - Livia Giannoni
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Aurelien Sutra Del Galy
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France
| | - Anne Brignier
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Therapeutic Apheresis Unit, Paris, France
| | - Flore Sicre de Fontbrune
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - David Michonneau
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France.,INSERM UMR 976, Paris, France
| | - Nathalie Dhedin
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
| | - Régis Peffault de Latour
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France
| | - Gérard Socié
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France.,Université de Paris, Paris, France.,INSERM UMR 976, Paris, France
| | - Marie Robin
- Assistance Publique Hôpitaux des Paris, Saint Louis Hospital, Hematology and Transplantation Unit, Paris, France
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141
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Comparative efficacy of 20 graft-versus-host disease prophylaxis therapies for patients after hematopoietic stem-cell transplantation: A multiple-treatments network meta-analysis. Crit Rev Oncol Hematol 2020; 150:102944. [DOI: 10.1016/j.critrevonc.2020.102944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/08/2020] [Accepted: 03/19/2020] [Indexed: 12/12/2022] Open
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142
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Sevrin F, Gonzales F, Machuron F, de Berranger E, Bruno B. Antithymocyte globulin in pediatric allogeneic hematopoietic stem cell transplantation: Infusion time and tolerability. Pediatr Transplant 2020; 24:e13694. [PMID: 32196861 DOI: 10.1111/petr.13694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Abstract
Antithymocyte globulin is a major drug in transplantation. rATG has been successfully used to prevent graft-versus-host disease in allogeneic HSCT. However, its first infusion is associated with reactions ranging from simple fevers to distributive shocks and may interfere with the transplant conditioning. To evaluate the impact of rATG infusion rate on clinical tolerability, we conducted a retrospective study of all pediatric allogeneic HSCT patients who received rATG (Thymoglobulin®) as part of their conditioning at Lille University Hospital from 2003 to 2018. Until 2012, patients received rATG with a theoretical infusion time of 12 hours (12H group, n = 33). From 2012, they had a theoretical infusion time of 4 hours (4H group, n = 43). Patients from the 12H arm presented more ≥ grade 3 infusion-related reactions at first dose (70% versus 44%, P = .027), had significantly higher fever (median of 39.6°C versus 39.2°C, P = .002), and needed a greater use of symptomatic treatments. However, they received a slightly higher first dose of rATG (median of 2.7 versus 2.3 mg/kg, P = .042). In view of these results, a rATG infusion time of 4 hours can be a relevant option for pediatric transplant centers to avoid interference with the conditioning regimen and facilitate medical surveillance.
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Affiliation(s)
- François Sevrin
- Service d'hématologie pédiatrique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Fanny Gonzales
- Service d'hématologie pédiatrique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | | | - Eva de Berranger
- Service d'hématologie pédiatrique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Benedicte Bruno
- Service d'hématologie pédiatrique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
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143
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Bonifazi F, Rubio MT, Bacigalupo A, Boelens JJ, Finke J, Greinix H, Mohty M, Nagler A, Passweg J, Rambaldi A, Socie G, Solano C, Walker I, Barosi G, Kröger N. Rabbit ATG/ATLG in preventing graft-versus-host disease after allogeneic stem cell transplantation: consensus-based recommendations by an international expert panel. Bone Marrow Transplant 2020; 55:1093-1102. [PMID: 31969678 PMCID: PMC7269907 DOI: 10.1038/s41409-020-0792-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/04/2019] [Accepted: 01/13/2020] [Indexed: 11/26/2022]
Abstract
This collaborative initiative aimed to provide recommendations on the use of polyclonal antithymocyte globulin (ATG) or anti-T lymphocyte globulin (ATLG) for the prevention of graft-versus-host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (HSCT). A comprehensive review of articles released up to October, 2018 was performed as a source of scientific evidence. Fourteen clinically relevant key questions to the domains indication, administration, and post-transplant management were developed and recommendations were produced using the Delphi technique involving a Panel of 14 experts. ATG/ATLG was strongly recommended as part of myeloablative conditioning regimen prior to matched or mismatched unrelated bone marrow or peripheral blood allogeneic HSCT in malignant diseases to prevent severe acute and chronic GvHD. ATG/ATLG was also recommended prior to HLA-identical sibling peripheral HSCT with good but lesser bulk of evidence. In reduced intensity or nonmyeloablative conditioning regimens, ATG/ATLG was deemed appropriate to reduce the incidence of acute and chronic GvHD, but a higher risk of relapse should be taken into account. Recommendations regarding dose, application, and premedication were also provided as well as post-transplant infectious prophylaxis and vaccination. Overall, these recommendations can be used for a proper and safe application of polyclonal ATG/ATLG to prevent GvHD after allogeneic HSCT.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "Seragnoli", University Hospital "S. Orsola Malpighi", Bologna, Italy.
| | - Marie-Thérèse Rubio
- Department of Hematology, Hôpital Brabois, CHRU Nancy and CNRS UMR 7365, Biopole del'Université del Lorraine, Vendoeuvre les Nancy, France
| | - Andrea Bacigalupo
- "Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy
- Institute of Hematology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, MSK Kids, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jürgen Finke
- Freiburg University Medical Faculty and Medical Center, Department for Medicine, Hematology, Oncology and Stem Cell Transplantation, Freiburg, Germany
| | - Hildegard Greinix
- Division of Hematology, Medical University of Graz, Auenbruggerplatz 38, 8036, Graz, Austria
| | - Mohamad Mohty
- Service d'Hématologie clinique et Thérapie cellulaire, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne University, INSERM UMRs 938, Paris, France
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Alessandro Rambaldi
- Department of Oncology, University of Milano and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Gérard Socie
- Service d' Hématologie-greffe, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Inserm UMR 976, Paris, France
| | - Carlos Solano
- Hematology Service, Hospital Clínico Universitario-INCLIVA; Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - Irwin Walker
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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144
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Use of anti-thymocyte globulin (ATG) for the treatment of pure red cell aplasia and immune-mediated cytopenias after allogeneic hematopoietic cell transplantation: a case series. Bone Marrow Transplant 2020; 55:2326-2330. [PMID: 32424188 DOI: 10.1038/s41409-020-0939-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/08/2022]
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145
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Guthoff M, Berger K, Althaus K, Mühlbacher T, Bakchoul T, Steurer W, Nadalin S, Königsrainer A, Heyne N. Low-dose alemtuzumab induction in a tailored immunosuppression protocol for sensitized kidney transplant recipients. BMC Nephrol 2020; 21:178. [PMID: 32404066 PMCID: PMC7218828 DOI: 10.1186/s12882-020-01767-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 03/16/2020] [Indexed: 01/08/2023] Open
Abstract
Background Induction therapy is crucial in kidney transplantation and constitutes an important cornerstone for long-term allograft survival. Alemtuzumab is a depleting CD52-specific antibody with T- and B-cell activity, leading to prolonged lymphocyte depletion for up to 12 months, with profound immunosuppression and an associated risk of serious infections. Current concepts aim to optimize dosing strategies to reduce side effects. Here we present data from an ongoing centre protocol consisting of low-dose alemtuzumab induction and tailored immunosuppression in sensitized patients undergoing kidney transplantation. Methods 10-year results of the protocol were analysed. Low-dose alemtuzumab induction consisted of a single dose of 20 mg intraoperatively, followed by tacrolimus and corticosteroids for initial immunosuppression, with mycophenolate mofetil suspended until a total lymphocyte count (TLC) >5% or 200/μl was reached. Results Between 01/2007 and 04/2017, 46 patients were treated in accordance with the protocol in 48 kidney transplantations. Median PRAmax was 43 [22-76; IQR] %; all patients had negative CDC-crossmatch prior to transplantation. Low-dose alemtuzumab was well tolerated. Median time to TLC recovery was 77 [62-127; IQR] d. Within a median follow-up of 3.3 [1.5-5.6; IQR] years, 12 (25%) patients developed BPAR, 10 of which were antibody-mediated (3 acute, 7 chronic ABMR). Death-censored 5-year allograft survival was 79.2%, with an excellent allograft function at the end of follow-up. There was no increased rate of infections, in particular viral infections. Conclusions Our protocol, comprising low-dose alemtuzumab induction, initial suspension of mycophenolate mofetil and triple maintenance immunosuppression, provides excellent patient and allograft outcome in sensitized renal allograft recipients.
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Affiliation(s)
- Martina Guthoff
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Otfried-Müller-Str. 47, 72076, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Kilian Berger
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, Otfried-Müller-Str. 4/1, 72076, Tübingen, Germany
| | - Thomas Mühlbacher
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Otfried-Müller-Str. 47, 72076, Tübingen, Germany.,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, Otfried-Müller-Str. 4/1, 72076, Tübingen, Germany
| | - Wolfgang Steurer
- Department of General- and Visceral Surgery, Leonberg Hospital, Rutesheimer Str. 50, 71229, Leonberg, Germany
| | - Silvio Nadalin
- Department of General-, Visceral- and Transplant Surgery, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Alfred Königsrainer
- Department of General-, Visceral- and Transplant Surgery, University of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Nils Heyne
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany. .,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Otfried-Müller-Str. 47, 72076, Tübingen, Germany. .,German Center for Diabetes Research (DZD e.V.), Neuherberg, Germany.
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146
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Puliyanda DP, Pizzo H, Rodig N, Somers MJG. Early outcomes comparing induction with antithymocyte globulin vs alemtuzumab in two steroid-avoidance protocols in pediatric renal transplantation. Pediatr Transplant 2020; 24:e13685. [PMID: 32112514 DOI: 10.1111/petr.13685] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/24/2020] [Accepted: 02/05/2020] [Indexed: 11/30/2022]
Abstract
Steroid avoidance in pediatric kidney transplants was found effective with extended daclizumab induction. Upon discontinuation of daclizumab, lymphocyte-depleting agents became used, with little comparative data. We assessed outcomes in children undergoing low immunologic-risk deceased donor (DD) kidney transplants using induction with antithymocyte globulin (ATG) compared to alemtuzumab. We reviewed consecutive DD kidney transplants from January 2015 to September 2017 at two pediatric centers that used different lymphocyte-depleting agents in steroid-avoidance protocols: ATG (Center A) and alemtuzumab (Center B), with tacrolimus and MMF as maintenance immunosuppression. Anti-infective prophylaxis was based on center protocol. Over the first year post-tx, there were similar rates of infections. EBV and BK viremia were comparable though Center A manifested more low-grade CMV viremia (A 46% vs B 0%; P = .0009) at median onset 1.8 months, followed by early seroconversion. Reduction of immunosuppression did not differ between groups. DSA at 1 year was similar (A 8% vs 13%) with low rates of BPAR. Need for steroid-based conversion was low. There were no graft losses and no differences in median eGFR at 30, 90, 180, and 365 days. (a) 1-year graft outcomes are excellent in steroid-avoidance regimens using ATG or alemtuzumab induction; (b) conversion to steroid-based therapy is low; (c) alemtuzumab/high-dose MMF is associated with lower WBC and more GCSF use; (d) alemtuzumab/higher dose MMF results in more diarrhea and azathioprine conversion than ATG/lower dose MMF; (e) CMV viremia is seen more often with ATG use with infection prophylaxis reduction; however, seroconversion occurs promptly.
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Affiliation(s)
- Dechu P Puliyanda
- Pediatric Nephrology and Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Helen Pizzo
- Pediatric Nephrology and Transplant Immunology, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Nancy Rodig
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael J G Somers
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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147
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Malard F, Huang XJ, Sim JPY. Treatment and unmet needs in steroid-refractory acute graft-versus-host disease. Leukemia 2020; 34:1229-1240. [PMID: 32242050 PMCID: PMC7192843 DOI: 10.1038/s41375-020-0804-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023]
Abstract
Acute graft-versus-host disease (aGVHD) is a common complication of allogeneic hematopoietic stem cell transplantation (alloHCT) and is a major cause of morbidity and mortality. Systemic steroid therapy is the first-line treatment for aGVHD, although about half of patients will become refractory to treatment. As the number of patients undergoing alloHCT increases, developing safe and effective treatments for aGVHD will become increasingly important, especially for those whose disease becomes refractory to systemic steroid therapy. This paper reviews current treatment options for patients with steroid-refractory aGVHD and discusses data from recently published clinical studies to outline emerging therapeutic strategies.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine (CRSA), UMRS_938, AP-HP Hôpital Saint-Antoine, F-75012, Paris, France.
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Joycelyn P Y Sim
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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148
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Boegeholz J, Brueggen CS, Pauli C, Dimitriou F, Haralambieva E, Dummer R, Manz MG, Widmer CC. Challenges in diagnosis and management of neutropenia upon exposure to immune-checkpoint inhibitors: meta-analysis of a rare immune-related adverse side effect. BMC Cancer 2020; 20:300. [PMID: 32290812 PMCID: PMC7155336 DOI: 10.1186/s12885-020-06763-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 03/17/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Cancer immunotherapy via immune-checkpoint inhibition (ICI) by antibodies against cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and cell death protein 1 (PD-1) have significantly improved the outcome of metastasized melanoma and of a rapidly increasing number of other cancer types. The anti-tumor effect is often accompanied by immune-related adverse events (irAE). Hematological irAE, specifically neutropenia, are rarely observed. However, neutropenia is associated with high morbidity and mortality due to infection complications. Thus, early detection and treatment is crucial. METHODS We present the clinical course of two patients with severe neutropenia after ICI therapy and demonstrate the difficulty of the diagnosis when a comedication of metamizole, a well-known analgesic drug used to treat cancer pain, is present. Further, we provide a comprehensive descriptive and statistical analysis of published data on diagnostics, treatment and infection complication in patients with at least grade 4 neutropenia by a systematic database search. RESULTS Finally, 34 patients were analyzed, including the two case reports from our cohort. The median onset of neutropenia was 10.5 weeks after first ICI administration (interquartile range: 6 weeks). In 76% (N = 26), a normalization of the neutrophil count was achieved after a median duration of neutropenia of 13 days. In a subsample of 22 patients with detailed data, the infection rate was 13%, proven by positive blood culture in 3 cases, but 68% (N = 15) presented with fever > 38 °C. Treatment regime differed relevantly, but mainly included G-CSF and intravenous corticosteroids. Death was reported in 14 patients (41%), 3 of whom (9%) were associated with hematological irAE but only two directly associated with neutropenia. CONCLUSION With an increasing number of cancer patients eligible to ICI therapy, the incidence of severe hematological toxicities may rise substantially over the next years. Clinicians working in the field of cancer immune therapies should be aware of neutropenia as irAE to provide immediate treatment.
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Affiliation(s)
- J Boegeholz
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | - C S Brueggen
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - C Pauli
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - F Dimitriou
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - E Haralambieva
- Institute of Pathology and Molecular Pathology, University Hospital Zurich, Zurich, Switzerland
| | - R Dummer
- Department of Dermatology, University and University Hospital Zurich, Zurich, Switzerland
| | - M G Manz
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | - C C Widmer
- Department of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland.
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Comparison of ATG-thymoglobulin with ATG-Fresenius for Epstein-Barr virus infections and graft-versus-host-disease in patients with hematological malignances after haploidentical hematopoietic stem cell transplantation: a single-center experience. Ann Hematol 2020; 99:1389-1400. [PMID: 32291495 PMCID: PMC7222941 DOI: 10.1007/s00277-020-04014-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/28/2020] [Indexed: 01/24/2023]
Abstract
Two anti-thymocyte globulin (ATG) forms are used in graft-versus-host disease (GVHD) prophylaxis during haploidentical hematopoietic stem cell transplantations (haplo-HSCTs): ATG-thymoglobulin (ATG-T) and ATG-fresenious (ATG-F). However, comparable dosages for haplo-HSCT remain unclear. We compared and evaluated the effects of ATG-T (7.5 mg/kg) or ATG-F (20 mg/kg) dosages in a relatively homogenous population in haplotype HSCT settings. Patients administered ATG-T 7.5 mg/kg (n = 81) or ATG-F 20 mg/kg (n = 35) as part of GVHD prophylaxis during haplo-HSCT were enrolled. Incidence and severity of GVHD, Epstein–Barr virus (EBV) infection, and immune cell recovery were compared using the Mann-Whitney U rank test and chi-square test. Cumulative incidences of GVHD, EBV infection and its subgroups, and relapse mortality were computed; overall survival (OS) was analyzed using the Kaplan-Meier method, with the log-rank test used for univariate comparison. Risk factors for OS were analyzed by the Cox proportional hazards model. Incidence and cumulative incidence of all grades of acute GVHD and subgroups were comparable in both groups (all p > 0.05); however, cumulative incidence of any grade and limited chronic GVHD was significantly higher in the ATG-T group (p = 0.002, p = 0.007, respectively). Cumulative incidences of EBV infections, EBV-DNAemia, and EBV-related diseases were similar; relapse mortality and OS rates were comparable between both groups (all p > 0.05). ATG-T dosage (7.5 mg/kg) appeared comparable to ATG-F dosage (20 mg/kg) for haplo-HSCT. Currently approved ATG-T and ATG-F doses appear efficient to balance the risk–benefit ratio of GVHD, OS, relapse mortality, and EBV infection in haplo-HSCT.
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150
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de Wolf ACMT, Herberts CA, Hoefnagel MHN. Dawn of Monitoring Regulatory T Cells in (Pre-)clinical Studies: Their Relevance Is Slowly Recognised. Front Med (Lausanne) 2020; 7:91. [PMID: 32300597 PMCID: PMC7142310 DOI: 10.3389/fmed.2020.00091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/03/2020] [Indexed: 12/14/2022] Open
Abstract
Regulatory T cells (Tregs) have a prominent role in the control of immune homeostasis. Pharmacological impact on their activity or balance with effector T cells could contribute to (impaired) clinical responses or adverse events. Monitoring treatment-related effects on T cell subsets may therefore be part of (pre-)clinical studies for medicinal products. However, the extent of immune monitoring performed in studies for marketing authorisation and the degree of correspondence with data available in the public domain is not known. We evaluated the presence of T cell immunomonitoring in 46 registration dossiers of monoclonal antibodies indicated for immune-related disorders and published scientific papers. We found that the depth of Treg analysis in registration dossiers was rather small. Nevertheless, data on treatment-related Treg effects are available in public academia-driven studies (post-registration) and suggest that Tregs may act as a biomarker for clinical responses. However, public data are fragmented and obtained with heterogeneity of experimental approaches from a diversity of species and tissues. To reveal the potential added value of T cell (and particular Treg) evaluation in (pre-)clinical studies, more cell-specific data should be acquired, at least for medicinal products with an immunomodulatory mechanism. Therefore, extensive analysis of T cell subset contribution to clinical responses and the relevance of treatment-induced changes in their levels is needed. Preferably, industry and academia should work together to obtain these data in a standardised manner and to enrich our knowledge about T cell activity in disease pathogenesis and therapies. This will ultimately elucidate the necessity of T cell subset monitoring in the therapeutic benefit-risk assessment.
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