Hyperacute graft-versus-host disease and NKT cells

Pre-engraftment graft-versus-host disease after allogeneic hematopoietic cell transplantation for acute leukemia

OBJECTIVES

Acute graft-versus-host disease (GVHD) usually occurs with neutrophil engraftment following allogeneic hematopoietic cell transplantation (HCT), but it can also occur before engraftment. We intended to analyze the effects of timing of acute GVHD on leukemia relapse and mortality.

METHODS

The outcomes of pre- and postengraftment GVHD were investigated in 384 patients who underwent allogeneic HCT for acute leukemia.

RESULTS

Acute GVHD occurred in 100 patients, pre-engraftment in 22 and postengraftment in 78. Compared with postengraftment GVHD, pre-engraftment GVHD was more severe, as assessed by overall grade, with more frequent and more severe skin involvement and higher incidences of non-infectious fever, diarrhea, hepatic dysfunction, renal insufficiency, and weight gain. Compared with patients without acute GVHD, those with postengraftment GVHD had lower cumulative incidence of relapse [CIR; hazard ratio (HR), 0.470; P=0.006] and higher cumulative incidence of non-relapse mortality (CINRM; HR, 2.568; P<0.001), while those with pre-engraftment GVHD had similar CIR (HR, 0.815; P=0.059) and higher CINRM (HR, 2.872; P=0.036). Overall survival of patients with pre-engraftment GVHD was lower than that of those without acute GVHD (HR, 1.976; P=0.017), which was similar to that of those with postengraftment GVHD (HR, 0.969; P=0.878). Separate analyses of the effects of timing of acute GVHD on post-transplant outcomes in patients with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) showed similar trends.

CONCLUSION

Pre-engraftment GVHD might be a 'cytokine storm' type syndrome rather than 'real' GVHD, indicating the need for separate analyses of pre- and postengraftment GVHD in future trials.

Clinical impact of hyperacute graft-versus-host disease on results of allogeneic stem cell transplantation

The current study defines the incidence and clinical manifestations of hyperacute graft-versus-host disease (haGVHD; fever, skin rash, diarrhea, and hepatic dysfunction) and analyzes the risk factor and the impact of haGVHD on the results of allogeneic stem cell transplantation (SCT). In all, 90 patients underwent allogeneic SCT from 71 matched siblings or 19 alternative donors. Immediate high-dose steroids were administered to 22 patients who met the criteria. The overall incidence of haGVHD was 36.7% (n=34) and haGVHD was also strongly correlated with acute (aGVHD) (P<0.001) and extensive chronic GVHD (cGVHD) (P=0.007), and found to be associated with decreased probability of relapse (P=0.0017). Early intervention with steroids within 7 days after the diagnosis of haGVHD might be associated with better survival. A survival analysis of the overall survival and disease-free survival did not reveal any difference between haGVHD+ and haGVHD- groups. In multivariate analysis, the use of an alternative donor (P=0.020) was identified as the only risk factor. Immediate high-dose steroids were effective in treating haGVHD. We conclude that in an allogeneic setting, haGVHD is not an uncommon manifestation, associated with the development of aGVHD or cGVHD. The only risk factor for haGVHD was the use of an alternative donor.