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Levine JE, Braun TM, Harris AC, Holler E, Taylor A, Miller H, Magenau J, Weisdorf DJ, Ho VT, Bolaños-Meade J, Alousi AM, Ferrara JLM. A prognostic score for acute graft-versus-host disease based on biomarkers: a multicentre study. LANCET HAEMATOLOGY 2014; 2:e21-9. [PMID: 26687425 DOI: 10.1016/s2352-3026(14)00035-0] [Citation(s) in RCA: 210] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 11/24/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is the major cause of non-relapse mortality after allogeneic haemopoietic stem-cell transplantation (SCT). The severity of symptoms at the onset of GVHD does not accurately define risk, and thus most patients are treated alike with high dose systemic corticosteroids. We aimed to define clinically meaningful risk strata for patients with newly diagnosed acute GVHD using plasma biomarkers. METHODS Between April 13, 2000, and May 7, 2013, we prospectively collected plasma from 492 SCT patients with newly diagnosed acute GVHD and randomly assigned (2:1) using a random number generator, conditional on the final two datasets having the same median day of onset, into training (n=328) and test (n=164) sets. We used the concentrations of three recently validated biomarkers (TNFR1, ST2, and Reg3α) to create an algorithm that computed the probability of non-relapse mortality 6 months after GVHD onset for individual patients in the training set alone. We rank ordered the probabilities and identified thresholds that created three distinct non-relapse mortality scores. We evaluated the algorithm in the test set, and again in an independent validation set of an additional 300 patients who underwent stem cell transplant and were enrolled on multicentre clinical trials of primary therapy for acute GVHD. FINDINGS In all three datasets (training, test, and validation), the cumulative incidence of 6-month non-relapse mortality significantly increased as the Ann Arbor GVHD score increased. In the multicentre validation set, scores were 8% (95% CI 3-16) for score 1, 27% (20-34) for score 2, and 46% (33-58) for score 3 (p<0·0001). Conversely, the response to primary GVHD treatment within 28 days decreased as the GVHD score increased 86% for score 1, 67% for score 2, and 46% for score 3 in the multicentre validation set, p<0·0001). INTERPRETATION Biomarker-based scores can be used to guide risk-adapted therapy at the onset of acute GVHD. High risk patients with a score of 3 are candidates for intensive primary therapy, while low risk patients with a score of 1 are candidates for rapid tapers of systemic steroid therapy. FUNDING The National Cancer Institute, the National Heart, Lung, and Blood Institute, the National Institute of Allergy and Infectious Diseases, the Doris Duke Charitable Fund, the American Cancer Society, and the Judith Devries Fund.
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Affiliation(s)
- John E Levine
- Blood & Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - Thomas M Braun
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Andrew C Harris
- Blood & Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - Ernst Holler
- Department of Hematology and Oncology, University of Regensburg, Regensburg, Germany
| | - Austin Taylor
- Blood & Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA; The Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Holly Miller
- Blood & Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - John Magenau
- Blood & Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA
| | - Daniel J Weisdorf
- Blood & Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
| | - Vincent T Ho
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, MA, USA
| | | | - Amin M Alousi
- Department of Stem Cell Transplantation, MD Anderson Cancer Center, Houston, TX, USA
| | - James L M Ferrara
- Blood & Marrow Transplant Program, University of Michigan, Ann Arbor, MI, USA; The Tisch Cancer Institute, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.
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202
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Betts B, Anasetti C, Pidala J. Biomarkers for GVHD prognosis. LANCET HAEMATOLOGY 2014; 2:e4-5. [PMID: 26687427 DOI: 10.1016/s2352-3026(14)00040-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/02/2014] [Indexed: 01/19/2023]
Affiliation(s)
- Brian Betts
- Department of Blood and Marrow Transplantation, Clinical Division, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA; Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
| | - Claudio Anasetti
- Department of Blood and Marrow Transplantation, Clinical Division, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA; Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA.
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, Clinical Division, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA; Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA
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203
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Abstract
Graft-versus-host disease (GvHD) remains a significant hurdle in overcoming the morbidity and mortality associated with haemopoietic stem cell transplantation in children. Better understanding of its pathobiology is facilitating the development of biomarkers for the severity of acute GvHD and treatment response, and has led to the introduction of a more prognostically relevant grading system for chronic GvHD. These enable stratification of appropriate prophylactic and treatment strategies according to the risk profiles of individual patients. Steroid-refractory acute GvHD has a poor prognosis, but early reports of the use of new immunosuppressive drugs and especially cellular treatments with extracorporeal photopheresis and mesenchymal stem cells suggest improved short-term outcomes and offer the promise of increased longer-term survival rates.
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Affiliation(s)
- S Dhir
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - M Slatter
- Children's Haemopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - R Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital, Newcastle upon Tyne, UK Children's Haemopoietic Stem Cell Transplant Unit, Great North Children's Hospital, Newcastle upon Tyne, UK
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204
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Brissot E, Bossard C, Malard F, Braudeau C, Chevallier P, Guillaume T, Delaunay J, Josien R, Gregoire M, Gaugler B, Mohty M. Involvement of the CX3CL1 (fractalkine)/CX3CR1 pathway in the pathogenesis of acute graft-versus-host disease. J Leukoc Biol 2014; 97:227-35. [PMID: 25420917 DOI: 10.1189/jlb.5hi0714-325r] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This study investigated the role of cytokines and chemokines in aGVHD incidence and severity in 109 patients who underwent reduced-intensity conditioning allogeneic stem cell transplantation (HSCT). Among the 42 cytokines tested at d 0 HSCT, only CX3CL1 levels at d 0 HSCT were significantly associated with Grades II-IV aGVHD development (P = 0.04). Increased levels of CX3CL1 at d 20-30 and 50 post-HSCT were also significantly associated with aGVHD (P = 0.02 and P = 0.03, respectively). No such association was found before the conditioning regimen or at d 100-120 post-HSCT. As the receptor for CX3CL1 is CX3CR1, the number of CX3CR1(+) cells was determined by flow cytometry. The CX3CR1(+)CD8(+) T cell proportion was significantly higher in patients with aGVHD than those without aGVHD (P = 0.01). To investigate the distribution of the CX3CL1/CX3CR1 axis in the anatomic sites of aGVHD, CX3CL1 and CX3CR1 levels were studied by use of an in situ immunohistochemical analysis on GI biopsies of patients with intestinal aGVHD. CX3CL1 expression was increased significantly in the epithelial cells and mononuclear cells of the lamina propria. CX3CR1(+) mononuclear cells were identified in close contact with epithelial cells. These findings strongly suggest the implication of the CX3CL1/CX3CR1 axis in the pathogenesis of aGVHD.
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Affiliation(s)
- Eolia Brissot
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Celine Bossard
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Florent Malard
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Cécile Braudeau
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Patrice Chevallier
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Thierry Guillaume
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jacques Delaunay
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Régis Josien
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marc Gregoire
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Beatrice Gaugler
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mohamad Mohty
- *Universite Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 938, Paris, France; Hématologie Clinique, Centre Hospitalier et Universitaire Hotel Dieu, Nantes, France; Le Centre Régional de Recherche en Cancérologie Nantes/Angers, Unité Mixte de Recherche 892 Institut National de la Santé et de la Recherche Médicale-6299 Centre National de la Recherche Scientifique, Nantes, France; EA4273 Biometadys, Faculté de Médecine, Université de Nantes, Nantes, France; Service d'Anatomie et Cytologie Pathologique and Laboratoire d'Immunologie, Plateforme d'Immuno-Monitorage Clinique, Centre Hospitalier et Universitaire de Nantes, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1098, Besançon, France; **Université de Franche-Comté, Besançon, France; Etablissement Français du Sang Bourgogne Franche-Comté, Besançon, France; Centre d'Investigation Clinique en Biothérapie CBT506, Plateforme de Biomonitoring, Besançon, France; and Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
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205
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High day 28 ST2 levels predict for acute graft-versus-host disease and transplant-related mortality after cord blood transplantation. Blood 2014; 125:199-205. [PMID: 25377785 DOI: 10.1182/blood-2014-06-584789] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
While cord blood transplantation (CBT) is an effective therapy for hematologic malignancies, acute graft-versus-host disease (aGVHD) is a leading cause of transplant-related mortality (TRM). We investigated if biomarkers could predict aGVHD and TRM after day 28 in CBT recipients. Day 28 samples from 113 CBT patients were analyzed. Suppressor of tumorigenicity 2 (ST2) was the only biomarker associated with grades II-IV and III-IV aGVHD and TRM. Day 180 grade III-IV aGVHD in patients with high ST2 levels was 30% (95% confidence interval [CI], 18-43) vs 13% (95% CI, 5-23) in patients with low levels (P = .024). The adverse effect of elevated ST2 was independent of HLA match. Moreover, high day 28 ST2 levels were associated with increased TRM with day 180 estimates of 23% (95% CI, 13-35) vs 5% (95% CI, 1-13) if levels were low (P = .001). GVHD was the most common cause of death in high ST2 patients. High concentrations of tumor necrosis factor receptor-1, interleukin-8, and regenerating islet-derived protein 3-α were also associated with TRM. Our results are consistent with those of adult donor allografts and warrant further prospective evaluation to facilitate future therapeutic intervention to ameliorate severe aGVHD and further improve survival after CBT.
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206
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Nelson RP, Khawaja MR, Perkins SM, Elmore L, Mumaw CL, Orschell C, Paczesny S. Prognostic biomarkers for acute graft-versus-host disease risk after cyclophosphamide-fludarabine nonmyeloablative allotransplantation. Biol Blood Marrow Transplant 2014; 20:1861-4. [PMID: 25017764 PMCID: PMC4194218 DOI: 10.1016/j.bbmt.2014.06.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 06/30/2014] [Indexed: 01/07/2023]
Abstract
Five candidate plasma biomarkers (suppression of tumorogenesis 2 [ST2], regenerating islet-derived-3α [REG3α], elafin, tumor necrosis factor receptor 1 [TNFR1], and soluble IL-2 receptor-alpha [sIL2Rα]) were measured at specific time points after cyclophosphamide/fludarabine-based nonmyeloablative allotransplantation (NMAT) in patients who did or did not develop acute graft-versus-host disease (aGVHD). Plasma samples from 34 patients were analyzed at days +7, +14, +21, and +30. At a median follow-up of 358 days, 17 patients had experienced aGVHD with a median time to onset at day +36. Risk of aGVHD was associated with elevated plasma ST2 concentrations at day +7 (c-statistic = .72, P = .03), day +14 (c-statistic = .74, P = .02), and day +21 (c-statistic = .75, P = .02); elevated plasma REG3α concentrations at day +14 (c-statistic = .73, P = .03), day +21 (c-statistic = .76, P = .01), and day +30 (c-statistic = .73, P = .03); and elevated elafin at day +14 (c-statistic = .71, P = .04). Plasma concentrations of TNFR1 and sIL2Rα were not associated with aGVHD risk at any of the time points studied. This study identified ST2, REG3α, and elafin as prognostic biomarkers to evaluate risk of aGVHD after cyclophosphamide/fludarabine-based NMAT. These results need to be confirmed in an independent validation cohort.
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Affiliation(s)
- Robert P. Nelson
- Division of Hematology/Oncology, Indiana University School of
Medicine and the Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
- Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, Indiana
| | - Muhammad Rizwan Khawaja
- Division of Hematology/Oncology, Indiana University School of
Medicine and the Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
| | - Susan M. Perkins
- Department of Biostatistics, Indiana University School of
Medicine, Indianapolis, Indiana
| | - Lindsey Elmore
- Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, Indiana
| | - Christen L. Mumaw
- Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, Indiana
| | - Christie Orschell
- Division of Hematology/Oncology, Indiana University School of
Medicine and the Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
| | - Sophie Paczesny
- Department of Pediatrics, Indiana University School of Medicine,
Indianapolis, Indiana
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207
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Paczesny S, Duncan C, Jacobsohn D, Krance R, Leung K, Carpenter P, Bollard C, Renbarger J, Cooke K. Opportunities and challenges of proteomics in pediatric patients: circulating biomarkers after hematopoietic stem cell transplantation as a successful example. Proteomics Clin Appl 2014; 8:837-50. [PMID: 25196024 DOI: 10.1002/prca.201400033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/30/2014] [Accepted: 09/03/2014] [Indexed: 11/06/2022]
Abstract
Biomarkers have the potential to improve diagnosis and prognosis, facilitate-targeted treatment, and reduce health care costs. Thus, there is great hope that biomarkers will be integrated in all clinical decisions in the near future. A decade ago, the biomarker field was launched with great enthusiasm because MS revealed that blood contains a rich library of candidate biomarkers. However, biomarker research has not yet delivered on its promise due to several limitations: (i) improper sample handling and tracking as well as limited sample availability in the pediatric population, (ii) omission of appropriate controls in original study designs, (iii) lability and low abundance of interesting biomarkers in blood, and (iv) the inability to mechanistically tie biomarker presence to disease biology. These limitations as well as successful strategies to overcome them are discussed in this review. Several advances in biomarker discovery and validation have been made in hematopoietic stem cell transplantation, the current most effective tumor immunotherapy, and these could serve as examples for other conditions. This review provides fresh optimism that biomarkers clinically relevant in pediatrics are closer to being realized based on: (i) a uniform protocol for low-volume blood collection and preservation, (ii) inclusion of well-controlled independent cohorts, (iii) novel technologies and instrumentation with low analytical sensitivity, and (iv) integrated animal models for exploring potential biomarkers and targeted therapies.
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Affiliation(s)
- Sophie Paczesny
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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Marafini I, Di Sabatino A, Zorzi F, Monteleone I, Sedda S, Cupi ML, Antenucci C, Biancheri P, Giuffrida P, Di Stefano M, Corazza GR, Pallone F, Monteleone G. Serum regenerating islet-derived 3-alpha is a biomarker of mucosal enteropathies. Aliment Pharmacol Ther 2014; 40:974-81. [PMID: 25112824 DOI: 10.1111/apt.12920] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 07/11/2014] [Accepted: 07/25/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND The clinical presentation of organic and functional intestinal disorders can overlap and clinicians often rely on invasive and time-consuming procedures to make a final diagnosis. Regenerating islet-derived 3-alpha (Reg3α) is detectable in the circulation of patients with intestinal graft-versus host disease and patients with inflammatory bowel disease (IBD). AIM To determine whether serum Reg3α testing is useful for discriminating mucosal enteropathies from functional intestinal disorders. METHODS We prospectively included 47 patients with active coeliac disease (ACD), 13 patients with refractory coeliac disease (RCD), seven patients with common variable immunodeficiency (CVID), 72 patients with active Crohn's disease, 22 patients with active ulcerative colitis (UC) and 28 patients with irritable bowel syndrome (IBS)-related diarrhoea. Sera were also taken from 10 CD patients before and after 6-12 months of a gluten-free diet (GFD) and from 14 patients with IBD before and after induction therapy with Infliximab (IFX). Sera of 119 healthy volunteers were used to determine the cut-off value. Reg3α levels were measured by a commercial ELISA kit. RESULTS Levels of Reg3α exceeded the cut-off value of the assay in 43/47(91%) ACD patients, 13/13(100%) RCD patients, 7/7(100%) CVID patients, 65/72(90%) Crohn's disease patients, 17/22(77%) UC patients and one patient with IBS(4%). Reg3α levels distinguished mucosal enteropathies from IBS with a sensitivity of 90% and a specificity of 96%. Reg3α levels significantly decreased in CD patients following a GFD and in IBD patients after treatment with IFX. CONCLUSION Reg3α is a serum biomarker of intestinal damage that, combined with clinical data, identifies patients who should undergo invasive tests for diagnosing enteropathies.
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Affiliation(s)
- I Marafini
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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209
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Mosevoll KA, Lindås R, Wendelbo O, Bruserud O, Reikvam H. Systemic levels of the endothelium-derived soluble adhesion molecules endocan and E-selectin in patients with suspected deep vein thrombosis. SPRINGERPLUS 2014; 3:571. [PMID: 25332871 PMCID: PMC4197195 DOI: 10.1186/2193-1801-3-571] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 09/19/2014] [Indexed: 12/11/2022]
Abstract
The initial evaluation of patients with suspected deep vein thrombosis includes the use of biomarkers reflecting activation of the coagulation system. However, the thromboembolic process and neighboring inflammatory responses also affect endothelial cells, and endothelial cell markers may therefore be altered by the disease. In the present population-based single-center study, we investigated the plasma levels of the endothelium-specific biomarkers soluble E-selectin and endocan in a consecutive and unselected group of 120 patients admitted to hospital for suspected deep vein thrombosis. Blood samples were collected when patients arrived at the hospital. DVT patients showed evidence for an acute phase reaction with increased serum C-reactive protein levels, but this was similar to many other patients admitted with suspected but not verified thrombosis. Plasma endocan and E-selectin levels did not differ between patients with thrombosis, healthy controls and the patients without verified thrombosis (i.e. patients with other causes of their symptoms, including various inflammatory and non-inflammatory conditions). However, the combined use of endothelial biomarkers, C-reactive protein and D-dimer could be used to identify patient subsets with different frequencies of venous thrombosis. Thus, analysis of plasma biomarker profiles including endothelial cell markers may be helpful in the initial evaluation of patients with deep vein thrombosis.
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Affiliation(s)
- Knut Anders Mosevoll
- Institute of Clinical Science, Section of Hematology, University of Bergen, Bergen, Norway
| | - Roald Lindås
- Section for Hematology, Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Oystein Wendelbo
- Section for Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Oystein Bruserud
- Institute of Clinical Science, Section of Hematology, University of Bergen, Bergen, Norway ; Section for Hematology, Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
| | - Håkon Reikvam
- Section for Hematology, Department of Medicine, Haukeland University Hospital, N-5021 Bergen, Norway
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210
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Graft-versus-host disease biomarkers: omics and personalized medicine. Int J Hematol 2014; 98:275-92. [PMID: 23959582 DOI: 10.1007/s12185-013-1406-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 07/29/2013] [Indexed: 02/03/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the most effective form of tumor immunotherapy available to date and the frequency of transplants continues to increase worldwide. However, while allo-HSCT usually induces a beneficial graft-versus leukemia effect, a major source of morbidity and mortality following allo-HSCT is graft-versus-host disease (GVHD). Currently available diagnostic and staging tools frequently fail to identify those at higher risk for GVHD morbidity, treatment unresponsiveness, and death. Furthermore, there are shortcomings in the risk stratification of patients before GVHD clinical signs develop. In parallel, recent years have been characterized by an explosive evolution of omics technologies, largely due to technological advancements in chemistry, engineering, and bioinformatics. Building on these opportunities, plasma biomarkers have been identified and validated as promising diagnostic and prognostic tools for acute GVHD. This review summarizes current information on the types of GVHD biomarkers, the omics tools used to identify them, the biomarkers currently validated as acute GVHD markers, and future recommendations for incorporating biomarkers into new grading algorithms for risk-stratifying patients and creating more personalized treatment courses. Future directions will include randomized evaluations of these biomarkers in multicenter prospective studies while extending on the need for biomarkers of chronic GVHD.
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211
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van der Velden WJFM, Herbers AHE, Netea MG, Blijlevens NMA. Mucosal barrier injury, fever and infection in neutropenic patients with cancer: introducing the paradigm febrile mucositis. Br J Haematol 2014; 167:441-52. [PMID: 25196917 DOI: 10.1111/bjh.13113] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Infection remains one of the most prominent complications after cytotoxic treatment for cancer. The connection between neutropenia and both infections and fever has long been designated as 'febrile neutropenia', but treatment with antimicrobial agents and haematopoietic growth factors has failed to significantly reduce its incidence. Moreover, emerging antimicrobial resistance is becoming a concern that necessitates the judicious use of available antimicrobial agents. In addition to neutropenia, patients who receive cytotoxic therapy experience mucosal barrier injury (MBI) or 'mucositis'. MBI creates a port-de-entrée for resident micro-organisms to cause blood stream infections and contributes directly to the occurrence of fever by disrupting the highly regulated host-microbe interactions, which, even in the absence of an infection, can result in strong inflammatory reactions. Indeed, MBI has been shown to be a pivotal factor in the occurrence of inflammatory complications after cytotoxic therapy. Hence, the concept 'febrile neutropenia' alone may no longer suffice and a new concept 'febrile mucositis' should be recognized as the two are at least complementary. This review we summarizes the existing evidence for both paradigms and proposes new therapeutic approaches to tackle the perturbed host-microbe interactions arising from cytotoxic therapy-induced tissue damage in order to reduce fever in neutropenic patients with cancer.
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212
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Slatter MA, Gennery AR. Advances in hematopoietic stem cell transplantation for primary immunodeficiency. Expert Rev Clin Immunol 2014; 9:991-9. [PMID: 24128161 DOI: 10.1586/1744666x.2013.836061] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The transplantation of hematopoietic stem cells in patients with primary immunodeficiencies has improved significantly over the last 40 years. In favorable circumstances when there is minimal or no infection present, no end-organ damage and the availability of a well HLA-matched donor, survival and cure reaches 90%. Barriers to further success include late identification of disease, with accumulation of infection- and inflammation-related organ damage, stem cell manipulation when there is no HLA-matched donor, toxicity of conditioning regimens and prediction and treatment of graft-versus-host disease. This review will outline recent developments in conditioning regimens, stem cell source manipulation and early detection and treatment of graft-versus-host disease, with a particular emphasis on patients with primary immunodeficiency.
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Affiliation(s)
- Mary A Slatter
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK and Department of Paediatric Immunology and HSCT, Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
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213
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Sorror ML, Martin PJ, Storb RF, Bhatia S, Maziarz RT, Pulsipher MA, Maris MB, Davis C, Deeg HJ, Lee SJ, Maloney DG, Sandmaier BM, Appelbaum FR, Gooley TA. Pretransplant comorbidities predict severity of acute graft-versus-host disease and subsequent mortality. Blood 2014; 124:287-95. [PMID: 24797298 PMCID: PMC4093684 DOI: 10.1182/blood-2014-01-550566] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/21/2014] [Indexed: 12/19/2022] Open
Abstract
Whether the hematopoietic cell transplantation comorbidity index (HCT-CI) can provide prognostic information about development of acute graft-versus-host disease (GVHD) and subsequent mortality is unknown. Five institutions contributed information on 2985 patients given human leukocyte antigen-matched grafts to address this question. Proportional hazards models were used to estimate the hazards of acute GVHD and post-GVHD mortality after adjustment for known risk variables. Higher HCT-CI scores predicted increased risk of grades 3 to 4 acute GVHD (P < .0001 and c-statistic of 0.64), and tests of interaction suggested that this association was consistent among different conditioning intensities, donor types, and stem cell sources. Probabilities of grades 3 to 4 GVHD were 13%, 18%, and 24% for HCT-CI risk groups of 0, 1 to 4, and ≥5. The HCT-CI was statistically significantly associated with mortality rates following diagnosis of grade 2 (hazard ratio [HR] = 1.24; P < .0001) or grades 3 to 4 acute GVHD (HR = 1.19; P < .0001). Patients with HCT-CI scores of ≥3 who developed grades 3 to 4 acute GVHD had a 2.63-fold higher risk of mortality than those with scores of 0 to 2 and did not develop acute GVHD. Thus, pretransplant comorbidities are associated with the development and severity of acute GVHD and with post-GVHD mortality. The HCT-CI could be useful in designing trials for GVHD prevention and could inform expectations for GVHD treatment trials.
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Affiliation(s)
- Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Paul J Martin
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Rainer F Storb
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | | | - Richard T Maziarz
- Center for Hematologic Malignancies, Knight Cancer Institute, and Division of Hematology and Medical Oncology, Oregon Health and Science University Knight Cancer Institute, Portland, OR
| | - Michael A Pulsipher
- Division of Hematology, University of Utah School of Medicine, Salt Lake City, UT; Pediatric Blood and Marrow Transplant Program, Primary Children's Medical Center, Huntsman Cancer Institute, Salt Lake City, UT
| | - Michael B Maris
- Colorado Blood Cancer Institute at Presbyterian/St. Luke's Medical Center, Denver, CO
| | - Christopher Davis
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - H Joachim Deeg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - David G Maloney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Theodore A Gooley
- Clinical Statistics Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; and Department of Biostatistics, University of Washington School of Public Health, Seattle, WA
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214
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Abstract
BACKGROUND The clinical prognosis of gastrointestinal (GI) graft-versus-host disease (GvHD) is based on either a clinical staging system or histological or endoscopic findings. How these different scores correlate with each other and which have the greater impact on transplantation outcomes is, however, not clear. METHODS Clinical, pathological, and endoscopic findings of the upper GI tract on 201 patients who underwent allogeneic hematopoietic stem cell transplantation were reviewed. The association between clinical, histological, and endoscopy grading was assessed by Kendall correlation coefficient. The agreement between grading systems was evaluated by kappa statistics. Factors associated with survival or steroid resistance were analyzed by proportional hazard models. RESULTS At disease onset, no strong association was found between pathological and clinical grade at disease onset (τ=0.034, P=0.6). In contrast, endoscopy score and clinical grades were strongly associated (τ=0.37, P<0.001). The Kappa concordance coefficient (0.20) between histological and endoscopy scores was poor. However, by multivariate analysis all three scores significantly predicted survival rates CONCLUSIONS Clinical, histological, and endoscopic scores poorly correlated with each other when estimated at the GI-GvHD onset. However, all three severe initial scores independently predict poor outcome. Of interest, clinical and endoscopic scores predict resistance to steroids while pathological does not.
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215
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De Bock M, Beguin Y, Leprince P, Willems E, Baron F, Deroyer C, Seidel L, Cavalier E, de Seny D, Malaise M, Gothot A, Merville MP, Fillet M. Comprehensive plasma profiling for the characterization of graft-versus-host disease biomarkers. Talanta 2014; 125:265-75. [DOI: 10.1016/j.talanta.2014.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 02/28/2014] [Accepted: 03/11/2014] [Indexed: 02/07/2023]
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Abstract
Over the past 5 years, many novel approaches to early diagnosis, prevention, and treatment of acute graft-versus-host disease (aGVHD) have been translated from the bench to the bedside. In this review, we highlight recent discoveries in the context of current aGVHD care. The most significant innovations that have already reached the clinic are prophylaxis strategies based upon a refinement of our understanding of key sensors, effectors, suppressors of the immune alloreactive response, and the resultant tissue damage from the aGVHD inflammatory cascade. In the near future, aGVHD prevention and treatment will likely involve multiple modalities, including small molecules regulating immunologic checkpoints, enhancement of suppressor cytokines and cellular subsets, modulation of the microbiota, graft manipulation, and other donor-based prophylaxis strategies. Despite long-term efforts, major challenges in treatment of established aGVHD still remain. Resolution of inflammation and facilitation of rapid immune reconstitution in those with only a limited response to corticosteroids is a research arena that remains rife with opportunity and urgent clinical need.
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217
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Arnaout K, Patel N, Jain M, El-Amm J, Amro F, Tabbara IA. Complications of allogeneic hematopoietic stem cell transplantation. Cancer Invest 2014; 32:349-62. [PMID: 24902046 DOI: 10.3109/07357907.2014.919301] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Infection, graft-versus-host disease (GVHD), and to a lesser extent sinusoidal obstructive syndrome (SOS) represent the major causes of morbidity and mortality in patients undergoing allogeneic hematopoietic stem cell transplantation (AHSCT). During the last decade, progress in prevention and treatment of these complications led to improvement in the outcome of these patients. Despite the fact that nonmyeloablative regimens have been increasingly used in elderly patients and in patients with co-morbidities, the nonrelapse related mortality remains a challenge and long-term follow-up is required. The objective of this manuscript is to provide an updated concise review of the complications of AHSCT and of the available treatment interventions.
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Affiliation(s)
- Karim Arnaout
- Department of Medicine, Division of Hematology and Oncology, George Washington University Medical Center, Washington, USA
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218
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Gatza E, Braun T, Levine JE, Ferrara JLM, Zhao S, Wang T, Chang L, Harris A, Pawarode A, Kitko C, Magenau JM, Yanik GA, Couriel DR, Goldstein S, Connelly J, Reddy P, Paczesny S, Choi SW. Etanercept plus topical corticosteroids as initial therapy for grade one acute graft-versus-host disease after allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20:1426-34. [PMID: 24892263 DOI: 10.1016/j.bbmt.2014.05.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 05/22/2014] [Indexed: 12/12/2022]
Abstract
Clinical diagnosis of grade 1 acute graft-versus-host disease (GVHD) marks the beginning of a potentially progressive and fatal course of GVHD after hematopoietic stem cell transplantation (HSCT). However, interventional studies to treat early GVHD are lacking. We conducted a single-arm prospective phase II trial to test the hypothesis that treatment of newly diagnosed grade 1 acute GVHD with etanercept and topical corticosteroids would reduce progression to grade 2 to 4 within 28 days. Study patients (n = 34) had a median age of 51 years (range, 10 to 67 years) and had undergone unrelated (n = 22) or related (n = 12) donor HSCT. Study patients were treated with etanercept (.4 mg/kg, maximum 25 mg/dose) twice weekly for 4 to 8 weeks. Ten of 34 patients (29%) progressed to grade 2 to 4 acute GVHD within 28 days. The cumulative incidence of grade 2 to 4 and grade 3 to 4 acute GVHD at 1 year was 41% and 3%, respectively. Nonrelapse mortality was 19% and overall survival was 63% at 2 years. Among a contemporaneous control cohort of patients who were diagnosed with grade 1 acute GVHD and treated with topical corticosteroids but not etanercept during the study period, 12 of 28 patients (43%) progressed to grade 2 to 4 GVHD within 28 days, with a 1-year incidence of grade 2 to 4 GVHD and grade 3 to 4 GVHD of 61% (41% versus 61%, P = .08) and 18% (3% versus 18%, P = .05), respectively. Patients treated with etanercept also experienced less increase in GVHD plasma biomarkers suppression of tumorigenicity 2 (P = .06) and regenerating islet-derived 3-alpha (P = .01) 28 days after grade 1 acute GVHD diagnosis compared with contemporaneous control patients. This study was terminated early because of poor accrual. Future prospective studies are needed to identify patients with grade 1 acute GVHD at risk of swift progression to more severe GVHD and to establish consensus for the treatment of grade 1 acute GVHD. This trial is registered with ClinicalTrials.gov, number NCT00726375.
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Affiliation(s)
- Erin Gatza
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Thomas Braun
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - John E Levine
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - James L M Ferrara
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Shuang Zhao
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Tianyi Wang
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Lawrence Chang
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Andrew Harris
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Carrie Kitko
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - John M Magenau
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gregory A Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Daniel R Couriel
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Steven Goldstein
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - James Connelly
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Pavan Reddy
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sophie Paczesny
- Department of Pediatrics, Indiana University, Indianapolis, Indiana
| | - Sung Won Choi
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
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Prognostic factors and outcomes of severe gastrointestinal GVHD after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2014; 49:966-71. [PMID: 24777184 PMCID: PMC4079749 DOI: 10.1038/bmt.2014.69] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We hypothesized that clinical risk factors could be identified within 2 weeks of onset of severe (stage 3 or 4) acute gut GVHD for identifying a patient population with a very poor outcome. Among 1462 patients who had allogeneic hematopoietic cell transplantation (HCT) between January 2000 and December 2005, 116 (7.9%) developed stage 3-4 gut GVHD. The median time for onset of stage 3-4 gut GVHD was 35 (4-135) days after allogeneic HCT. Eighty-five of the 116 patients (73%) had corticosteroid resistance before or within 2 weeks after the onset of stage 3-4 gut GVHD. Significant risk factors for mortality included corticosteroid resistance (hazards ratio (HR)=2.93; P=0.0005), age >18 years (HR=4.95; P=0.0004), increased serum bilirubin (HR 2.53; P=0.0001) and overt gastrointestinal bleeding (HR 2.88; P=0.0004). Among patients with stage 3-4 gut GVHD, the subgroup with 0, 1 or 2 risk factors had a favorable prognosis, whereas the subgroup with 3 or 4 risk factors had a dismal prognosis. This information should be considered in designing future studies of severe gut GVHD and in counseling patients about prognosis.
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220
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Pernemalm M, Lehtiö J. Mass spectrometry-based plasma proteomics: state of the art and future outlook. Expert Rev Proteomics 2014; 11:431-48. [PMID: 24661227 DOI: 10.1586/14789450.2014.901157] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Mass spectrometry-based plasma proteomics is a field where intense research has been performed during the last decade. Being closely linked to biomarker discovery, the field has received a fair amount of criticism, mostly due to the low number of novel biomarkers reaching the clinic. However, plasma proteomics is under gradual development with improvements on fractionation methods, mass spectrometry instrumentation and analytical approaches. These recent developments have contributed to the revival of plasma proteomics. The goal of this review is to summarize these advances, focusing in particular on fractionation methods, both for targeted and global mass spectrometry-based plasma analysis.
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Affiliation(s)
- Maria Pernemalm
- Karolinska Institutet, Science for Life Laboratory, Tomtebodavägen 23, 171 65, Solna, Sweden
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221
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Soluble interleukin-2 receptor level on day 7 as a predictor of graft-versus-host disease after HLA-haploidentical stem cell transplantation using reduced-intensity conditioning. Int J Hematol 2014; 99:463-70. [PMID: 24599414 DOI: 10.1007/s12185-014-1542-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/13/2014] [Accepted: 02/13/2014] [Indexed: 01/01/2023]
Abstract
In the present study, we analyzed the kinetics of serum soluble interleukin-2 receptor (sIL-2R) using data from 77 patients undergoing HLA-haploidentical transplantation using reduced-intensity conditioning (RIC), who were at an advanced stage or at high risk for relapse, to clarify the usefulness of sIL-2R as a biomarker of acute graft-versus-host disease (GVHD). Anti-T-lymphocyte globulin and methylprednisolone were used as GVHD prophylaxis. While the median sIL-2R in 38 patients not developing GVHD was suppressed at levels <740 U/ml, sIL-2R in 25 patients developing severe GVHD peaked on day 11 (1,663 U/ml), and thereafter decreased to <1,000 U/ml after day 30. The occurrence of GVHD was not limited to times of high sIL-2R level, but occurred at any time point on the sIL-2R curve. Most patients developing GVHD, however, experienced a higher sIL-2R level early in their transplant course. The combination of RIC and glucocorticoids sufficiently suppressed sIL-2R levels after HLA-haploidentical transplantation. In a multivariate analysis to identify factors associated with GVHD, day 7 sIL-2R >810 U/ml was the only factor significantly associated with the occurrence of severe GVHD (p = 0.0101).
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222
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Goldberg JD, Giralt S. Assessing response of therapy for acute and chronic graft-versus-host disease. Expert Rev Hematol 2014; 6:103-7. [DOI: 10.1586/ehm.12.65] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Newell LF, Deans RJ, Maziarz RT. Adult adherent stromal cells in the management of graft-versus-host disease. Expert Opin Biol Ther 2014; 14:231-46. [DOI: 10.1517/14712598.2014.866648] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
There are no validated biomarkers for chronic GVHD (cGVHD). We used a protein microarray and subsequent sequential enzyme-linked immunosorbent assay to compare 17 patients with treatment-refractory de novo-onset cGVHD and 18 time-matched control patients without acute or chronic GVHD to identify 5 candidate proteins that distinguished cGVHD from no cGVHD: CXCL9, IL2Rα, elafin, CD13, and BAFF. We then assessed the discriminatory value of each protein individually and in composite panels in a validation cohort (n = 109). CXCL9 was found to have the highest discriminatory value with an area under the receiver operating characteristic curve of 0.83 (95% confidence interval, 0.74-0.91). CXCL9 plasma concentrations above the median were associated with a higher frequency of cGVHD even after adjustment for other factors related to developing cGVHD including age, diagnosis, donor source, and degree of HLA matching (71% vs 20%; P < .001). A separate validation cohort from a different transplant center (n = 211) confirmed that CXCL9 plasma concentrations above the median were associated with more frequent newly diagnosed cGVHD after adjusting for the aforementioned factors (84% vs 60%; P = .001). Our results confirm that CXCL9 is elevated in patients with newly diagnosed cGVHD.
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225
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Ayuk F, Bussmann L, Zabelina T, Veit R, Alchalby H, Wolschke C, Lellek H, Bacher U, Zander AR, Kröger N. Serum albumin level predicts survival of patients with gastrointestinal acute graft-versus-host disease after allogeneic stem cell transplantation. Ann Hematol 2013; 93:855-61. [PMID: 24248672 DOI: 10.1007/s00277-013-1957-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 11/04/2013] [Indexed: 11/29/2022]
Abstract
In a retrospective single-centre study, we analysed the prognostic impact of factors identifiable at initial diagnosis of acute GVHD (aGVHD). We retrospectively analysed 495 adult patients of whom 308 (62 %) developed acute GVHD (I-IV) and were included in further analysis. Gut aGVHD was diagnosed in 163/308 cases (53 %). Conditioning was myeloablative conditioning (MAC) in 123 (39.9 %) and reduced intensity (RIC) in 185 (60.1 %) patients. Median serum albumin level at diagnosis of aGVHD was 34 g/l, which was used as cut-off for low vs. normal albumin levels. In patients with gut aGVHD, low albumin level at the time of diagnosis of aGVHD was associated with poorer overall survival (OS) which was 52 vs. 67 % at 1 year and 40 vs. 61 % at 3 years, p = 0.015. In patients with only skin aGVHD, 1- and 3-year OS of patients with low vs. normal albumin levels were 72 vs. 72 % and 59 vs. 57 %, respectively, p = 0.69. In multivariate analysis of patients with gut aGVHD, low serum albumin level ≤34 g/l (relative risk (RR) 2.13, p = 0.003), gut aGVHD grades 3-4 (RR 2.70, p = 0.001), RIC (RR 1.84, p = 0.024), matched unrelated donor (RR 1.86, p = 0.18) and mismatched unrelated donor (RR 2.76, p = 0.03) retained negative impact on OS. Subgroup analysis revealed that impact of albumin was restricted to patients with gut aGVHD after RIC. Low serum albumin levels are associated with poorer OS in patients with gut but not skin aGVHD after RIC but not MAC allogeneic stem cell transplantation.
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Affiliation(s)
- Francis Ayuk
- Clinic for stem cell transplantation, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20245, Hamburg, Germany,
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226
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Abstract
In this issue of Blood, Levine et al present an intriguing analysis highlighting the potential clinical impact of Paneth cell loss in gastrointestinal (GI) acute graft-versus-host disease (GVHD).
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227
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Sung AD, Chao NJ. Acute graft-versus-host disease: are we close to bringing the bench to the bedside? Best Pract Res Clin Haematol 2013; 26:285-92. [PMID: 24309532 DOI: 10.1016/j.beha.2013.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplant (AHSCT) associated with significant morbidity and mortality. This review focuses on the pathophysiology, prevention, and treatment of acute GVHD. Specifically, we explain how new discoveries in immunology have expanded our understanding of GVHD, in which tissue damage from chemotherapy or radiation results in cytokine release, activating T cells, resulting in proliferation and differentiation, trafficking to target organs, and tissue destruction and inflammation. Insights into the mechanisms of this disease relate directly to the development of preventive strategies and therapies, such as immunosuppression, calcineurin inhibitors, T-cell depletion, CCR5 antagonists, gut decontamination, extracorporeal photopheresis, and more. Understanding the immunobiology of GVHD and developing effective preventions and treatments are critical to the continuing success of AHSCT.
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Affiliation(s)
- Anthony D Sung
- Duke University Medical Center, Division of Hematologic Malignancies and Cellular Therapy, 2400 Pratt St, Suite 9100, Box 3961, Durham, NC 27710, USA.
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228
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Liu A, Meyer E, Johnston L, Brown J, Gerson LB. Prevalence of graft versus host disease and cytomegalovirus infection in patients post-haematopoietic cell transplantation presenting with gastrointestinal symptoms. Aliment Pharmacol Ther 2013; 38:955-66. [PMID: 24003975 DOI: 10.1111/apt.12468] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 07/18/2013] [Accepted: 08/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is lack of consensus regarding whether both upper and lower endoscopic examinations are required for diagnosis of gastrointestinal acute graft versus host disease (GI-AGVHD). AIM To evaluate the impact of endoscopic procedures on the diagnosis of GI-AGVHD. METHODS We performed a retrospective case-control study of recipients of allogeneic haematopoetic cell transplant (HCT) from 2000 to 2011, who presented with GI symptoms between 20 and 125 days post-HCT. GI-AGVHD status was based on the National Institutes of Health (NIH) clinical grading system. RESULTS One hundred and twenty-nine clinical GI-AGVHD cases and 184 controls underwent endoscopic examinations. Diarrhoea was present in 73% of cases and 38% of controls (P < 0.0001); 99% of patients with nausea ± vomiting and diarrhoea underwent bidirectional endoscopy. Histology had a sensitivity of 92% and specificity of 91% compared to the clinical criteria. The sensitivity for GI-AGVHD was 80% or greater when upper endoscopy (EGD) was performed with either sigmoidoscopy or colonoscopy, or if lower endoscopic examinations were performed alone. The sensitivity of EGD alone was only 48% (P = 0.003). Sensitivity was highest with biopsy of the terminal ileum (79%), followed by the ascending (74%), transverse/descending (73%) and sigmoid colons (69%). Diagnostic yield for cytomegalovirus (CMV) infection was equivalent for biopsies from both upper and lower GI tracts. Patients found to have concurrent GI-AGVHD and CMV infection (N = 18) had a poorer overall prognosis. CONCLUSION In patients post-HCT with GI symptoms, sigmoidoscopy alone had equivalent diagnostic yield for GI-AGVHD and CMV infection, compared with the addition of EGD or performance of full colonoscopy.
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Affiliation(s)
- A Liu
- Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
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229
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Hansen JA, Hanash SM, Tabellini L, Baik C, Lawler RL, Grogan BM, Storer B, Chin A, Johnson M, Wong CH, Zhang Q, Martin PJ, McDonald GB. A novel soluble form of Tim-3 associated with severe graft-versus-host disease. Biol Blood Marrow Transplant 2013; 19:1323-30. [PMID: 23791624 PMCID: PMC3966623 DOI: 10.1016/j.bbmt.2013.06.011] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 06/10/2013] [Indexed: 12/24/2022]
Abstract
The T cell Ig and mucin domain 3 (Tim-3) receptor has been implicated as a negative regulator of adaptive immune responses. We have utilized a proteomic strategy to identify novel proteins associated with graft versus host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT). Mass spectrometry analysis of plasma from subjects with mid-gut and upper-gut GVHD compared with those without GVHD identified increased levels of a protein identified with high confidence as Tim-3. A follow-up validation study using an immunoassay to measure Tim-3 levels in individual plasma samples from 127 patients demonstrated significantly higher plasma Tim-3 concentrations in patients with the more severe mid-gut GVHD, compared with those with upper-gut GVHD (P = .005), patients without GVHD (P = .002), and normal controls (P < .0001). Surface expression of Tim-3 was increased on CD8(+) T cells from patients with grade 2 to 4 acute GVHD (P = .01). Mass spectrometry-based profiling of plasma from multiple subjects diagnosed with common diseases provided evidence for restricted release of soluble Tim-3 in the context of GVHD. These findings have mechanistic implications for the development of novel strategies for targeting the Tim-3 immune regulatory pathway as an approach to improving control of GVHD.
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Affiliation(s)
- John A Hansen
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington 98109-1024, USA.
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230
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Calkoen FGJ, Jol-van der Zijde CM, Mearin ML, Schweizer JJ, Jansen-Hoogendijk AM, Roelofs H, van Halteren AGS, Egeler RM, van Tol MJD, Ball LM. Gastrointestinal acute graft-versus-host disease in children: histology for diagnosis, mesenchymal stromal cells for treatment, and biomarkers for prediction of response. Biol Blood Marrow Transplant 2013; 19:1590-9. [PMID: 23994245 DOI: 10.1016/j.bbmt.2013.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 08/21/2013] [Indexed: 12/23/2022]
Abstract
Steroid-nonresponsive acute graft-versus-host disease (aGVHD) after hematopoietic stem cell transplantation carries a poor prognosis. Various groups have reported beneficial effects of mesenchymal stromal cell (MSC) infusion as salvage treatment. Response to treatment is typically evaluated using the diagnostic clinical criteria for aGVHD. In this study, we evaluated the usefulness of additional gastrointestinal biopsy specimens paired with serum biomarkers. In a cohort of 22 pediatric patients, persistent or recurrent diarrhea was seen in 18 children treated with MSC infusion for steroid-refractory aGVHD. To exclude other causes of gastrointestinal pathology, patients were biopsied for histological analysis. Eight of 12 patients exhibited residual tissue damage and villous atrophy, but no active aGVHD. Serum biomarkers have been identified as an alternative tool for monitoring the response to aGVHD treatment. The value of biomarkers for inflammation, tissue, and endothelial cell damage was evaluated in our cohort. Although predictive of response to treatment and survival, these markers lack the necessary specificity and sensitivity to predict response to MSC therapy. Objective endpoints for clinical trials on the treatment of steroid-refractory aGVHD remain to be defined. Thus, we recommend including biopsies and biomarkers to discriminate between ongoing aGVHD and postinflammatory malabsorption.
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Affiliation(s)
- Friso G J Calkoen
- Immunology, Hematology/Oncology and Hematopoietic Stem Cell Transplantation Section, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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231
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Vander Lugt MT, Braun TM, Hanash S, Ritz J, Ho VT, Antin JH, Zhang Q, Wong CH, Wang H, Chin A, Gomez A, Harris AC, Levine JE, Choi SW, Couriel D, Reddy P, Ferrara JLM, Paczesny S. ST2 as a marker for risk of therapy-resistant graft-versus-host disease and death. N Engl J Med 2013; 369:529-39. [PMID: 23924003 PMCID: PMC3943357 DOI: 10.1056/nejmoa1213299] [Citation(s) in RCA: 289] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND No plasma biomarkers are associated with the response of acute graft-versus-host disease (GVHD) to therapy after allogeneic hematopoietic stem-cell transplantation. METHODS We compared 12 biomarkers in plasma obtained a median of 16 days after therapy initiation from 10 patients with a complete response by day 28 after therapy initiation and in plasma obtained from 10 patients with progressive GVHD during therapy. The lead biomarker, suppression of tumorigenicity 2 (ST2), was measured at the beginning of treatment for GVHD in plasma from 381 patients and during the first month after transplantation in three independent sets totaling 673 patients to determine the association of this biomarker with treatment-resistant GVHD and 6-month mortality after treatment or transplantation. RESULTS Of the 12 markers, ST2 had the most significant association with resistance to GVHD therapy and subsequent death without relapse. As compared with patients with low ST2 values at therapy initiation, patients with high ST2 values were 2.3 times as likely to have treatment-resistant GVHD (95% confidence interval [CI], 1.5 to 3.6) and 3.7 times as likely to die within 6 months after therapy (95% CI, 2.3 to 5.9). Patients with low ST2 values had lower mortality without relapse than patients with high ST2 values, regardless of the GVHD grade (11% vs. 31% among patients with grade I or II GVHD and 14% vs. 67% among patients with grade III or IV GVHD, P<0.001 for both comparisons). Plasma ST2 values at day 14 after transplantation were associated with 6-month mortality without relapse, regardless of the intensity of the conditioning regimen. CONCLUSIONS ST2 levels measured at the initiation of therapy for GVHD and during the first month after transplantation improved risk stratification for treatment-resistant GVHD and death without relapse after transplantation. (Funded by the National Institutes of Health.)
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232
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Eriguchi Y, Uryu H, Nakamura K, Shimoji S, Takashima S, Iwasaki H, Miyamoto T, Shimono N, Hashimoto D, Akashi K, Ayabe T, Teshima T. Reciprocal expression of enteric antimicrobial proteins in intestinal graft-versus-host disease. Biol Blood Marrow Transplant 2013; 19:1525-9. [PMID: 23927965 DOI: 10.1016/j.bbmt.2013.07.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 07/31/2013] [Indexed: 01/06/2023]
Abstract
We recently demonstrated that expression of α-defensins, the major antimicrobial peptides produced by Paneth cells, was severely suppressed in mice with graft-versus-host disease (GVHD). In this study, we found that antibacterial lectin, regenerating islet-derived IIIγ (RegIIIγ) was upregulated in villous enterocytes, thus demonstrating the reciprocal control of enteric antimicrobial proteins in GVHD. Upregulation of RegIIIγ was mediated by a mechanism independent upon radiation-induced intestinal tract damage. MyD88-mediated signaling in intestinal epithelium was required for RegIIIγ upregulation in GVHD and antibiotic therapy downregulated RegIIIγ expression. These results suggest that MyD88-mediated sensing of the intestinal microbes disregulated in GVHD induces RegIIIγ upregulation in GVHD and argue a role for RegIIIγ in the pathogenesis of GVHD.
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Affiliation(s)
- Yoshihiro Eriguchi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Science, Fukuoka, Japan
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233
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Proteomic peptide profiling for preemptive diagnosis of acute graft-versus-host disease after allogeneic stem cell transplantation. Leukemia 2013; 28:842-52. [PMID: 23842427 PMCID: PMC7101954 DOI: 10.1038/leu.2013.210] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 06/25/2013] [Accepted: 07/02/2013] [Indexed: 01/22/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation is one curative treatment for hematological malignancies, but is compromised by life-threatening complications, such as severe acute graft-versus-host disease (aGvHD). Prediction of severe aGvHD as early as possible is crucial to allow timely initiation of treatment. Here we report on a multicentre validation of an aGvHD-specific urinary proteomic classifier (aGvHD_MS17) in 423 patients. Samples (n=1106) were collected prospectively between day +7 and day +130 and analyzed using capillary electrophoresis coupled on-line to mass spectrometry. Integration of aGvHD_MS17 analysis with demographic and clinical variables using a logistic regression model led to correct classification of patients developing severe aGvHD 14 days before any clinical signs with 82.4% sensitivity and 77.3% specificity. Multivariate regression analysis showed that aGvHD_MS17 positivity was the only strong predictor for aGvHD grade III or IV (P<0.0001). The classifier consists of 17 peptides derived from albumin, β2-microglobulin, CD99, fibronectin and various collagen α-chains, indicating inflammation, activation of T cells and changes in the extracellular matrix as early signs of GvHD-induced organ damage. This study is currently the largest demonstration of accurate and investigator-independent prediction of patients at risk for severe aGvHD, thus allowing preemptive therapy based on proteomic profiling.
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234
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Couturier M, Lamarthée B, Arbez J, Renauld JC, Bossard C, Malard F, Bonnefoy F, Mohty M, Perruche S, Tiberghien P, Saas P, Gaugler B. IL-22 deficiency in donor T cells attenuates murine acute graft-versus-host disease mortality while sparing the graft-versus-leukemia effect. Leukemia 2013; 27:1527-37. [PMID: 23399894 DOI: 10.1038/leu.2013.39] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 01/20/2013] [Accepted: 02/06/2013] [Indexed: 12/24/2022]
Abstract
Acute graft-versus-host disease (aGVHD) remains a major complication following allogeneic hematopoietic cell transplantation (allo-HCT), limiting the success of this therapy. Many proinflammatory cytokines secreted following the conditioning regimen have been linked to aGVHD initiation. Interleukin-22 (IL-22) is a cytokine related to IL-10 for its structure and is secreted by T helper type 17 (TH17) cells and innate immune cells. Given the paradoxical role of IL-22 in inflammation with both protective or proinflammatory functions, we investigated whether IL-22 could have a role in aGVHD pathophysiology in a mouse allo-HCT model. In this study, we show that IL-22 deficiency in donor T cells can decrease the severity of aGVHD, while limiting systemic and local inflammation in aGVHD target organs. In addition, we found that Foxp3+ regulatory T cells (Treg cells) were increased in recipient mice that received IL-22-deficient T cells, suggesting that Treg were involved in the reduced severity of GVHD. Finally, we found that the graft-versus-leukemia (GVL) effect mediated by donor T cells was preserved in the absence of IL-22. Overall, these data suggest that targeting of IL-22 may represent a valid approach towards decreasing aGVHD severity after allo-HCT while preserving the GVL effect.
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235
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Low Paneth cell numbers at onset of gastrointestinal graft-versus-host disease identify patients at high risk for nonrelapse mortality. Blood 2013; 122:1505-9. [PMID: 23760615 DOI: 10.1182/blood-2013-02-485813] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Acute graft-versus-host disease (GVHD) of the gastrointestinal (GI) tract is an often lethal complication of allogeneic hematopoietic cell transplant. Clinical severity correlates with outcomes, but histopathologic grading is primarily used to confirm the clinical diagnosis. One barrier to using histopathologic grading to predict clinical outcomes is inter-grader variability among transplant centers. Recent experimental models have shown that the loss of Paneth cells, which are located in the small intestine and help regulate the GI microbiome by secreting antimicrobial peptides, correlates with clinical GVHD severity. Because Paneth cells are easy to identify and quantify by light microscopy, we evaluated the mean number of Paneth cells per high-powered field (hpf) in 116 duodenal biopsies obtained at diagnosis of GI GVHD at 2 different centers with their clinical outcomes. Paneth cell counts were reproducible between centers (r(2) = 0.81; P < .0001). Lower numbers of Paneth cells at diagnosis correlated with clinically more severe GI GVHD (P < .0001) and less likelihood of response to GVHD treatment (P < .0001). A threshold of 4 Paneth cells per hpf stratified patients according to nonrelapse mortality (28% vs 56%; P = .004). We conclude that the enumeration of duodenal Paneth cells is a readily available index of disease severity that provides important information regarding GVHD prognosis.
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236
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Lochmanová G, Jedličková L, Potěšil D, Tomancová A, Verner J, Pospíšilová S, Doubek M, Mayer J, Zdráhal Z. Potential biomarkers for early detection of acute graft-versus-host disease. Proteomics Clin Appl 2013; 6:351-63. [PMID: 22927351 DOI: 10.1002/prca.201100104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute graft-versus-host disease (aGVHD) is the main complication of allogeneic hematopoietic stem cell transplantation (HCT), resulting in considerable morbidity and mortality. Currently, the diagnosis of aGVHD is largely made based on clinical parameters and invasive biopsies. For the past 20 years, researchers have been trying to find reliable biomarkers to enable early and accurate diagnosis of aGVHD. Although a number of potential aGVHD biomarkers have been published, as yet, no validated diagnostic test is available. Proteomics encompasses a broad range of rapidly developing technologies, which have shown tremendous promise for early detection of aGVHD. In this article, we review the current state of aGVHD biomarker discovery, provide a summary of the key proteins of interest and the most common analytical procedures for the clinic, as well as outlining the significant challenges faced in their use.
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Affiliation(s)
- Gabriela Lochmanová
- Core Facility-Proteomics, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
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237
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Berger M, Signorino E, Muraro M, Quarello P, Biasin E, Nesi F, Vassallo E, Fagioli F. Monitoring of TNFR1, IL-2Rα, HGF, CCL8, IL-8 and IL-12p70 following HSCT and their role as GVHD biomarkers in paediatric patients. Bone Marrow Transplant 2013; 48:1230-6. [PMID: 23584443 DOI: 10.1038/bmt.2013.41] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 02/21/2013] [Accepted: 02/25/2013] [Indexed: 11/12/2022]
Abstract
No predictive factors are currently available to establish patient-specific GVHD risk. A panel of six serum cytokines (TNF receptor 1, IL-2 receptor alfa (IL-2Rα), hepatocyte growth factor (HGF), monocyte chemo-attractant protein-2, IL-8, IL-12p70) were monitored at established time points (days -1, +1, +7, +14, +21, +28 and +60) in 170 paediatric hematopoietic SCT (HSCT) recipients. We found that higher concentrations of IL-2Rα on days +14 and +21 together with HGF on days +14 and +21 were significantly associated at a higher probability of both grade II-IV GVHD (on day +14 it was: 60% vs 28%, P=0.007) and grade III-IV (on day +14 it was: 40% vs 15%, P=0.001). The higher IL-8 serum concentration on day +28 was associated with a lower probability of chronic GVHD being 4% vs 29% (P=0.01) for patients with higher vs lower IL-8 serum concentration. These findings were confirmed when the analysis was restricted to the the matched unrelated donor group. In conclusion, even if the serum cytokine levels were related to several variables associated with HSCT, we identified two cytokines as predictors of GVHD II-IV and III-IV, translating into a higher TRM risk (17% vs 3%, P=0.004).
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Affiliation(s)
- M Berger
- Paediatric Onco-Hematology and Stem Cell Transplant Unit, Stem Cell Transplantation and Cellular Therapy Division, Regina Margherita Children's Hospital, Piazza Polonia 94, Turin, Italy.
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Ceruloplasmin is a potential biomarker for aGvHD following allogeneic hematopoietic stem cell transplantation. PLoS One 2013; 8:e58735. [PMID: 23505556 PMCID: PMC3591372 DOI: 10.1371/journal.pone.0058735] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/05/2013] [Indexed: 01/01/2023] Open
Abstract
Acute graft-versus-host-disease (aGvHD) is the major cause of non-relapse mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Recently, diagnostic biomarkers for aGvHD have been shown to play important roles in evaluating disease status and mortality risk after allo-HSCT. To identify plasma biomarkers for aGvHD with high sensitivity and specificity, a quantitative proteomic approach using 8-plex isobaric tags for relative and absolute quantitation (8-plex iTRAQ) was employed to screen differentially expressed proteins in peripheral blood before and after the onset of aGvHD. Four target proteins, ceruloplasmin (CP), myeloperoxidase (MPO), complement factor H (CFH), and alpha-1-acid glycoprotein (AGP), were chosen for preliminary validation with enzyme linked immunosorbent assay (ELISA) in 20 paired samples at both the time of diagnosis of aGvHD and the time of complete response. The most promising candidate, ceruloplasmin, was further validated at fixed time points after allo-HSCT and during aGvHD. The plasma ceruloplasmin levels were significantly increased during the period of aGvHD onset and were markedly decreased as aGvHD resolved. The plasma ceruloplasmin levels at different time points post-transplant in the aGvHD (+) group were significantly higher than those in the aGvHD (-) group (p<0.001). The elevation of ceruloplasmin level in patients with active aGvHD was independent of infection status. Patients whose ceruloplasmin levels were elevated above 670 μg/ml at 7, 14 and 21 days after allo-HSCT had a remarkably increased probability of subsequently developing aGvHD. In conclusion, our results suggest that plasma ceruloplasmin is a potential plasma biomarker of aGvHD, and it also has prognostic value for risk-adapted prophylaxis during the consecutive time points monitored in the first month after allo-HSCT.
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239
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Reikvam H, Fredly H, Kittang AO, Bruserud Ø. The possible diagnostic and prognostic use of systemic chemokine profiles in clinical medicine—the experience in acute myeloid leukemia from disease development and diagnosis via conventional chemotherapy to allogeneic stem cell transplantation. Toxins (Basel) 2013; 5:336-62. [PMID: 23430540 PMCID: PMC3640539 DOI: 10.3390/toxins5020336] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 12/29/2022] Open
Abstract
Chemokines are important regulators of many different biological processes, including (i) inflammation with activation and local recruitment of immunocompetent cells; (ii) angiogenesis as a part of inflammation or carcinogenesis; and (iii) as a bridge between the coagulation system and inflammation/immune activation. The systemic levels of various chemokines may therefore reflect local disease processes, and such variations may thereby be used in the routine clinical handling of patients. The experience from patients with myeloproliferative diseases, and especially patients with acute myeloid leukemia (AML), suggests that systemic plasma/serum cytokine profiles can be useful, both as a diagnostic tool and for prognostication of patients. However, cytokines/chemokines are released by a wide range of cells and are involved in a wide range of biological processes; the altered levels may therefore mainly reflect the strength and nature of the biological processes, and the optimal clinical use of chemokine/cytokine analyses may therefore require combination with organ-specific biomarkers. Chemokine levels are also altered by clinical procedures, therapeutic interventions and the general status of the patients. A careful standardization of sample collection is therefore important, and the interpretation of the observations will require that the overall clinical context is considered. Despite these limitations, we conclude that analysis of systemic chemokine/cytokine profiles can reflect important clinical characteristics and, therefore, is an important scientific tool that can be used as a part of future clinical studies to identify clinically relevant biomarkers.
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Affiliation(s)
- Håkon Reikvam
- Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway; E-Mails: (H.R.); (H.F.)
- Institute of Medicine, University of Bergen, Bergen N-5021, Norway; E-Mail:
| | - Hanne Fredly
- Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway; E-Mails: (H.R.); (H.F.)
- Institute of Medicine, University of Bergen, Bergen N-5021, Norway; E-Mail:
| | | | - Øystein Bruserud
- Section for Hematology, Department of Medicine, Haukeland University Hospital, Bergen N-5021, Norway; E-Mails: (H.R.); (H.F.)
- Institute of Medicine, University of Bergen, Bergen N-5021, Norway; E-Mail:
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240
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Lyu YX, Yu XC, Zhu MY. Comparison of the diagnostic value of procalcitonin and C-reactive protein after hematopoietic stem cell transplantation: a systematic review and meta-analysis. Transpl Infect Dis 2013; 15:290-9. [PMID: 23387529 DOI: 10.1111/tid.12055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 09/24/2012] [Accepted: 09/25/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Y.-X. Lyu
- Cancer Center; Xinchang People's Hospital; Zhejiang; China
| | - X.-C. Yu
- Clinical Laboratory; Xinchang People's Hospital; Zhejiang; China
| | - M.-Y. Zhu
- Clinical Laboratory; Xinchang People's Hospital; Zhejiang; China
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241
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Current practice in diagnosis and treatment of acute graft-versus-host disease: results from a survey among German-Austrian-Swiss hematopoietic stem cell transplant centers. Biol Blood Marrow Transplant 2013; 19:767-76. [PMID: 23376495 DOI: 10.1016/j.bbmt.2013.01.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/23/2013] [Indexed: 12/19/2022]
Abstract
To assess current clinical practice in diagnosis and treatment of acute graft-versus-host disease (aGVHD), we performed a survey among German, Austrian, and Swiss allogeneic hematopoietic stem cell transplantation (allo-HSCT) centers. Thirty-four of 72 contacted centers (47%) completed both the diagnostic and therapeutic sections of the survey, representing 65% of allo-HSCT activity within the participating countries in 2011. Three pediatric centers answered as requested only the diagnostic part of the survey. In the presence of diarrhea and decreased oral intake after engraftment, only 4 centers (12%) do not perform any endoscopy before the start of immunosuppressive treatment. In case of a skin rash with the differential diagnosis of drug reaction, only 12 centers (35%) perform a skin biopsy up front, whereas 19 do so after failure of systemic steroids. In the presence of rapidly increasing cholestasis occurring without any other signs of aGVHD, 11 centers (32%) perform a liver biopsy up front and 14 only after failure of steroid treatment, whereas 9 centers do not perform a liver biopsy at all. Twenty centers (59%) use a percutaneous approach, 12 a transvenous approach, and 1 mini-laparoscopy for liver biopsies. First-line treatment of cutaneous aGVHD stage 1 consists of topical treatment alone in 17 of 31 responding centers (61%), whereas isolated cutaneous aGVHD stage III is treated with systemic steroids (prednisolone below 0.5 mg/kg/day n = 2, 0.5 to 1.0 mg/kg/day n = 10, above 1.0 to 2.5 mg/kg/day n = 19) without or with topical agents (steroids n = 10; calcineurin inhibitors n = 3). In gastrointestinal manifestations of aGVHD, 9 centers (29%) add topical to systemic steroids, and 3 consider topical steroids as the only treatment for mild gastrointestinal and cutaneous aGVHD. The choice of agent for second-line treatment as well as the sequence of administration are extremely heterogeneous, most likely due to a lack of convincing data published. Most frequently used are mycophenolate mofetil (n = 14) and extracorporeal photopheresis (n = 10). Our survey also demonstrates that clinicians chose salvage therapies for steroid-refractory aGVHD based on their centers' own clinical experience.
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242
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Sung AD, Chao NJ. Concise review: acute graft-versus-host disease: immunobiology, prevention, and treatment. Stem Cells Transl Med 2012; 2:25-32. [PMID: 23283494 DOI: 10.5966/sctm.2012-0115] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplant (AHSCT) associated with significant morbidity and mortality. This review focuses on the pathophysiology, clinical features, prevention, and treatment of acute GVHD. Specifically, we explain how new discoveries in immunology have expanded our understanding of GVHD, in which tissue damage from chemotherapy or radiation results in cytokine release, which activates T cells, resulting in proliferation and differentiation, trafficking to target organs, and tissue destruction and inflammation. Insights into the mechanisms of this disease relate directly to the development of preventive strategies and therapies, such as immunosuppression, T-cell depletion, calcineurin inhibitors, CCR5 antagonists, gut decontamination, extracorporeal photopheresis, and more. We also discuss how GVHD affects the gut, liver, and skin, as well as diagnosis, grading, and scoring. We end by examining future directions of treatment, including new immunomodulators and biomarkers. Understanding the immunobiology of GVHD and developing effective preventions and treatments are critical to the continuing success of AHSCT.
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243
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Abstract
Acute graft-versus-host disease (GVHD) is a leading cause of non-relapse mortality following allogeneic haematopoietic cell transplantation. Attempts to improve treatment response in clinically-established GVHD have not improved overall survival, often due to the increased risk of infectious complications. Alternative approaches to decrease GVHD-related morbidity and mortality have focused on the ability to predict GVHD prior to clinical manifestation in an effort to provide an opportunity to abort GVHD development, and to gain new insights into GVHD pathophysiology. This review outlines the research efforts to date that have identified clinical and laboratory-based factors that are predictive of acute GVHD and describes future directions in developing algorithms that will improve the ability to predict the development of clinically relevant GVHD.
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Affiliation(s)
- Andrew C Harris
- Blood and Marrow Transplant Program, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI 48109, USA
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244
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Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the most effective tumor immunotherapy available. Although allo-HSCT provides beneficial graft-versus-tumor effects, acute GVHD (aGVHD) is the primary source of morbidity and mortality after HSCT. Diagnosis of aGVHD is typically based on clinical symptoms in one or more of the main target organs (skin, liver, gastrointestinal tract) and confirmed by biopsy. However, currently available diagnostic and staging tools often fail to identify patients at higher risk of GVHD progression, unresponsiveness to therapy, or death. In addition, there are shortcomings in the prediction of GVHD before clinical signs develop, indicating the urgent need for noninvasive and reliable laboratory tests. Through the continuing evolution of proteomics technologies seen in recent years, plasma biomarkers have been identified and validated as promising diagnostic tools for GVHD and prognostic tools for nonrelapse mortality. These biomarkers may facilitate timely and selective therapeutic intervention but should be more widely validated and incorporated into a new grading system for risk stratification of patients and better-customized treatment. This review identifies biomarkers for detecting GVHD, summarizes current information on aGVHD biomarkers, proposes future prospects for the blinded evaluation of these biomarkers, and discusses the need for biomarkers of chronic GVHD.
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245
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Fiema B, Harris AC, Gomez A, Pongtornpipat P, Lamiman K, Vander Lugt MT, Paczesny S. High throughput sequential ELISA for validation of biomarkers of acute graft-versus-host disease. J Vis Exp 2012:4247. [PMID: 23149907 PMCID: PMC3499072 DOI: 10.3791/4247] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Unbiased discovery proteomics strategies have the potential to identify large numbers of novel biomarkers that can improve diagnostic and prognostic testing in a clinical setting and may help guide therapeutic interventions. When large numbers of candidate proteins are identified, it may be difficult to validate candidate biomarkers in a timely and efficient fashion from patient plasma samples that are event-driven, of finite volume and irreplaceable, such as at the onset of acute graft-versus-host disease (GVHD), a potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation (HSCT). Here we describe the process of performing commercially available ELISAs for six validated GVHD proteins: IL-2Rα5, TNFR16, HGF7, IL-88, elafin2, and REG3α3 (also known as PAP1) in a sequential fashion to minimize freeze-thaw cycles, thawed plasma time and plasma usage. For this procedure we perform the ELISAs in sequential order as determined by sample dilution factor as established in our laboratory using manufacturer ELISA kits and protocols with minor adjustments to facilitate optimal sequential ELISA performance. The resulting plasma biomarker concentrations can then be compiled and analyzed for significant findings within a patient cohort. While these biomarkers are currently for research purposes only, their incorporation into clinical care is currently being investigated in clinical trials. This technique can be applied to perform ELISAs for multiple proteins/cytokines of interest on the same sample(s) provided the samples do not need to be mixed with other reagents. If ELISA kits do not come with pre-coated plates, 96-well half-well plates or 384-well plates can be used to further minimize use of samples/reagents.
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Affiliation(s)
- Bryan Fiema
- Pediatric Blood and Marrow Transplant Program, University of Michigan
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246
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Abstract
One reason for the lack of progress in the treatment of acute graft versus host disease (GVHD) is the lack of reliable biomarkers. GVHD of the gastrointestinal (GI) tract is closely associated with non-relapse mortality (NRM) following hematopoietic cell transplantation (HCT). Using an unbiased, large-scale, quantitative proteomic discovery approach, we identified candidate biomarkers that were increased in plasma from HCT patients with GI GVHD. We then validated the lead candidate, REG3α, by ELISA in samples from more than 1000 HCT patients from three transplant centers. Plasma REG3α concentrations were 3-fold higher in patients at GI GVHD onset than in all other patients. REG3α concentrations correlated most closely with lower GI GVHD at GVHD onset and predicted response to therapy at 4 weeks, 1-year NRM, and 1-year survival (P ≤ 0.001). Multivariate analysis showed that advanced clinical stage, severe histologic damage, and high REG3α concentrations at the diagnosis of GVHD independently predicted 1-year NRM, which progressively increased with higher numbers of onset risk factors present. We conclude that REG3α is a plasma biomarker of GI GVHD that can be combined with clinical stage and histologic grade to improve risk stratification of patients, perhaps providing a platform for advances in the treatment of high-risk GVHD.
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Affiliation(s)
- Andrew C Harris
- University of Michigan Medical School, 6303 Cancer Center, 1500 East Medical Center Drive, Ann Arbor, MI 4810, USA
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247
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Abstract
Even in 2012, almost 45 years after the first successful allogeneic bone marrow transplants, infection remains the most common cause of nonrelapse transplant-related mortality.(1)
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248
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Ukena SN, Geffers R, Buchholz S, Stadler M, Franzke A. Biomarkers for acute and chronic graft-versus-host disease in regulatory T cells. Transpl Immunol 2012; 27:179-83. [PMID: 22889700 DOI: 10.1016/j.trim.2012.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 07/29/2012] [Indexed: 12/21/2022]
Abstract
Despite improvements in the prevention and treatment of graft-versus-host disease (GvHD) this allogeneic immune response is still one of major complications following allogeneic stem cell transplantation (SCT). Identification of patients at risk for the development of acute and chronic GvHD would facilitate early intervention and thus improve overall survival. Diagnostic biomarkers identified in plasma are largely associated with T cell immune responses. Whereas donor effector T cells promote allogeneic immune responses, regulatory T cells (Tregs) may prevent GvHD by suppression of these alloreactive donor T cells. Therefore, we analyzed molecules associated with Tregs with respect to their potential predictive and prognostic impact on the development of acute and chronic GvHD. For this purpose, the Treg transcriptomes of patients with and without acute/chronic GvHD resulting from dynamical whole genome profiles of CD4(+)CD25(hi)CD127(lo/-) Tregs have been studied for potential GvHD biomarkers. We could identify potential biomarkers for acute/chronic GvHD like the activation marker phosphatidyl-5-kinase-gamma PIP5Kγ, FAS, CD44, CD69, and cell cycle regulators like cyclin A2, B1 and E2. Most importantly, the IKAROS transcription factor Eos, relevant for suppressive Treg function, might be relevant for the prediction of GvHD development. In addition markers like ANK3 (ankyrin), S100A8 and VCAN are indicative for acute GvHD, while IFIT3, IFI44 and IFIT1 are potential biomarkers for chronic GvHD. The identified markers have to be validated prospectively and might help to monitor and guide preventive immune intervention studies, especially adoptive donor Treg cell transfer.
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Affiliation(s)
- Sya N Ukena
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
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249
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Acute graft-versus-host disease biomarkers measured during therapy can predict treatment outcomes: a Blood and Marrow Transplant Clinical Trials Network study. Blood 2012; 119:3854-60. [PMID: 22383800 DOI: 10.1182/blood-2012-01-403063] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Acute graft-versus-host disease (GVHD) is the primary limitation of allogeneic hematopoietic cell transplantation, and once it develops, there are no reliable diagnostic tests to predict treatment outcomes. We hypothesized that 6 previously validated diagnostic biomarkers of GVHD (IL-2 receptor-α; tumor necrosis factor receptor-1; hepatocyte growth factor; IL-8; elafin, a skin-specific marker; and regenerating islet-derived 3-α, a gastrointestinal tract-specific marker) could discriminate between therapy responsive and nonresponsive patients and predict survival in patients receiving GVHD therapy. We measured GVHD biomarker concentrations from samples prospectively obtained at the initiation of treatment, day 14, and day 28, on a multicenter, randomized, 4-arm phase 2 clinical trial for newly diagnosed acute GVHD. We found that at each of 3 time points, GVHD onset, 2 weeks into treatment, and 4 weeks into treatment, a 6-protein biomarker panel predicted for the important clinical outcomes of day 28 posttherapy nonresponse and mortality at day 180 from onset. GVHD biomarker panels can be used for early identification of patients at high or low risk for treatment nonresponsiveness or death, and they may provide opportunities for early intervention and improved survival after hematopoietic cell transplantation. The study was registered in clinicaltrials.gov as NCT00224874.
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250
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Abstract
The lower gastrointestinal tract (LGI) and liver are the GVHD target organs most associated with treatment failure and nonrelapse mortality. We recently identified regenerating islet-derived 3-α (REG3α) as a plasma biomarker of LGI GVHD. We compared REG3α with 2 previously reported GI and liver GVHD diagnostic biomarkers, hepatocyte growth factor (HGF) and cytokeratin fragment 18, in 954 hematopoietic cell transplantation patients. All 3 biomarkers were significantly elevated in LGI GVHD compared with non-GVHD diarrhea; REG3α discerned LGI GVHD from non-GVHD diarrhea better than HGF and cytokeratin fragment 18. Although all 3 biomarkers predicted nonresponse to therapy at day 28 in LGI GVHD patients, only REG3α and HGF concentrations predicted 1-year nonrelapse mortality (P = .01 and P = .02, respectively). Liver GVHD without GI involvement at GVHD onset and non-GVHD liver complications were uncommon; all 3 biomarkers were elevated in liver GVHD, but did not distinguish GVHD from other causes of hyperbilirubinemia.
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