1
|
Jamy O, Zeiser R, Chen YB. Novel developments in the prophylaxis and treatment of acute GVHD. Blood 2023; 142:1037-1046. [PMID: 37471585 DOI: 10.1182/blood.2023020073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/27/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023] Open
Abstract
Acute graft-versus-host disease (aGVHD) is a major life-threatening complication after allogeneic hematopoietic cell transplant. Traditional standard prophylaxis for aGVHD has included a calcineurin inhibitor plus an antimetabolite, whereas treatment has relied mainly on corticosteroids, followed by multiple nonstandard second-line options. In the past decade, this basic framework has been reshaped by approval of antithymocyte globulin products, the emergence of posttransplant cyclophosphamide, and recent pivotal trials studying abatacept and vedolizumab for GVHD prophylaxis, whereas ruxolitinib was approved for corticosteroid-refractory aGVHD treatment. Because of this progress, routine acute GVHD prophylaxis and treatment practices are starting to shift, and results of ongoing trials are eagerly awaited. Here, we review recent developments in aGVHD prevention and therapy, along with ongoing and future planned clinical trials in this space, outlining what future goals should be and the limitations of current clinical trial designs and end points.
Collapse
Affiliation(s)
- Omer Jamy
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cell Therapy Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
2
|
Al Malki MM, London K, Baez J, Akahoshi Y, Hogan WJ, Etra A, Choe H, Hexner E, Langston A, Abhyankar S, Ponce DM, DeFilipp Z, Kitko CL, Adekola K, Reshef R, Ayuk F, Capellini A, Chanswangphuwana C, Eder M, Eng G, Gandhi I, Grupp S, Gleich S, Holler E, Javorniczky NR, Kasikis S, Kowalyk S, Morales G, Özbek U, Rösler W, Spyrou N, Yanik G, Young R, Chen YB, Nakamura R, Ferrara JLM, Levine JE. Phase 2 study of natalizumab plus standard corticosteroid treatment for high-risk acute graft-versus-host disease. Blood Adv 2023; 7:5189-5198. [PMID: 37235690 PMCID: PMC10505783 DOI: 10.1182/bloodadvances.2023009853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023] Open
Abstract
Graft-versus-host disease (GVHD) of the gastrointestinal (GI) tract is the main cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation. Ann Arbor (AA) scores derived from serum biomarkers at onset of GVHD quantify GI crypt damage; AA2/3 scores correlate with resistance to treatment and higher NRM. We conducted a multicenter, phase 2 study using natalizumab, a humanized monoclonal antibody that blocks T-cell trafficking to the GI tract through the α4 subunit of α4β7 integrin, combined with corticosteroids as primary treatment for patients with new onset AA2/3 GVHD. Seventy-five patients who were evaluable were enrolled and treated; 81% received natalizumab within 2 days of starting corticosteroids. Therapy was well tolerated with no treatment emergent adverse events in >10% of patients. Outcomes for patients treated with natalizumab plus corticosteroids were compared with 150 well-matched controls from the MAGIC database whose primary treatment was corticosteroids alone. There were no significant differences in overall or complete response between patients treated with natalizumab plus corticosteroids and those treated with corticosteroids alone (60% vs 58%; P = .67% and 48% vs 48%; P = 1.0, respectively) including relevant subgroups. There were also no significant differences in NRM or overall survival at 12 months in patients treated with natalizumab plus corticosteroids compared with controls treated with corticosteroids alone (38% vs 39%; P = .80% and 46% vs 54%; P = .48, respectively). In this multicenter biomarker-based phase 2 study, natalizumab combined with corticosteroids failed to improve outcome of patients with newly diagnosed high-risk GVHD. This trial was registered at www.clinicaltrials.gov as # NCT02133924.
Collapse
Affiliation(s)
- Monzr M. Al Malki
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Kaitlyn London
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Sunil Abhyankar
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS
| | - Doris M. Ponce
- Division of Hematology/Oncology, Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Kehinde Adekola
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ran Reshef
- Blood and Marrow Transplantation, Columbia University Medical Center, New York, NY
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Isha Gandhi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan Grupp
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nora Rebeka Javorniczky
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Özbek
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wolf Rösler
- Department of Internal Medicine 5, University Hospital Erlangen, Erlangen, Germany
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregory Yanik
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
3
|
Fukuta T, Muramatsu H, Yamashita D, Sajiki D, Maemura R, Tsumura Y, Yamamori A, Imaya M, Wakamatsu M, Nishikawa E, Narita K, Kataoka S, Taniguchi R, Narita A, Nishio N, Takahashi Y. Vedolizumab for children with intestinal graft-versus-host disease: a case report and literature review. Int J Hematol 2023; 118:411-417. [PMID: 37074509 DOI: 10.1007/s12185-023-03590-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/20/2023]
Abstract
Acute graft-versus-host disease (aGVHD) is a challenging complication of allogeneic hematopoietic stem cell transplantation, and alternative therapies for patients showing inadequate response to steroids are limited. Vedolizumab, an anti-α4β7 integrin antibody widely used for treating inflammatory bowel diseases, has recently been studied in adult patients with steroid-refractory intestinal aGVHD. However, few studies have examined its safety and effectiveness in pediatric patients with intestinal aGVHD. We report the case of a male patient with intestinal late-onset aGVHD treated with vedolizumab. He underwent allogeneic cord blood transplantation for warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) syndrome and developed intestinal late-onset aGVHD 31 months after transplantation. The patient was refractory to steroids; however, vedolizumab was initiated 43 months after transplantation (at the age of 7 years) and the symptoms of intestinal aGVHD were alleviated. Additionally, favorable endoscopic findings were observed, such as reduction of erosion and regenerative epithelial growth. We also evaluated the efficacy of vedolizumab in 10 patients with intestinal aGVHD (9 from the literature review and the present case). Six patients (60%) showed an objective response to vedolizumab. No serious adverse events were observed in any patients. Vedolizumab is a potential treatment option for steroid-refractory intestinal aGVHD in pediatric patients.
Collapse
Affiliation(s)
- Taro Fukuta
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Hideki Muramatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan.
| | - Daiki Yamashita
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Daichi Sajiki
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Ryo Maemura
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Yusuke Tsumura
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Ayako Yamamori
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Masayuki Imaya
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Manabu Wakamatsu
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Eri Nishikawa
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Kotaro Narita
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Shinsuke Kataoka
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Rieko Taniguchi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Atsushi Narita
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Nobuhiro Nishio
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Yoshiyuki Takahashi
- Department of Pediatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan.
| |
Collapse
|
4
|
Larson JH, Jin S, Loschi M, Bolivar Wagers S, Thangavelu G, Zaiken MC, McDonald-Hyman C, Saha A, Aguilar EG, Koehn B, Osborn MJ, Panoskaltsis-Mortari A, Macdonald KPA, Hill GR, Murphy WJ, Serody JS, Maillard I, Kean LS, Kim SV, Littman DR, Blazar BR. Enforced gut homing of murine regulatory T cells reduces early graft-versus-host disease severity. Am J Transplant 2023; 23:1102-1115. [PMID: 36878433 PMCID: PMC10475494 DOI: 10.1016/j.ajt.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/31/2023] [Indexed: 03/07/2023]
Abstract
Damage to the gastrointestinal tract following allogeneic hematopoietic stem cell transplantation is a significant contributor to the severity and perpetuation of graft-versus-host disease. In preclinical models and clinical trials, we showed that infusing high numbers of regulatory T cells reduces graft-versus-host disease incidence. Despite no change in in vitro suppressive function, transfer of ex vivo expanded regulatory T cells transduced to overexpress G protein-coupled receptor 15 or C-C motif chemokine receptor 9, specific homing receptors for colon or small intestine, respectively, lessened graft-versus-host disease severity in mice. Increased regulatory T cell frequency and retention within the gastrointestinal tissues of mice that received gut homing T cells correlated with lower inflammation and gut damage early post-transplant, decreased graft-versus-host disease severity, and prolonged survival compared with those receiving control transduced regulatory T cells. These data provide evidence that enforced targeting of ex vivo expanded regulatory T cells to the gastrointestinal tract diminishes gut injury and is associated with decreased graft-versus-host disease severity.
Collapse
Affiliation(s)
- Jemma H Larson
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sujeong Jin
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael Loschi
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sara Bolivar Wagers
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Govindarajan Thangavelu
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael C Zaiken
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Cameron McDonald-Hyman
- Division of Hematology/Oncology/Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Asim Saha
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ethan G Aguilar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Brent Koehn
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mark J Osborn
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Angela Panoskaltsis-Mortari
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kelli P A Macdonald
- Infection and Inflammation Program, QIMR Berghofer Medical Research Institute, Immunology Department, Brisbane, Queensland, Australia
| | - Geoffrey R Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA; Division of Medical Oncology, University of Washington, Seattle, Washington, USA
| | - William J Murphy
- Department of Dermatology, University of California Davis School of Medicine, Sacramento, California, USA; Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Jonathan S Serody
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Computational Medicine Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ivan Maillard
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leslie S Kean
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Sangwon V Kim
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dan R Littman
- Molecular Pathogenesis Program, The Kimmel Center for Biology and Medicine of the Skirball Institute, New York University School of Medicine, New York, USA; Howard Hughes Medical Institute, New York University School of Medicine, New York, USA
| | - Bruce R Blazar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA.
| |
Collapse
|
5
|
[Vedolizumab for treatment of steroid-refractory intestinal acute graft-versus-host disease: two cases report and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:1046-1049. [PMID: 36709113 PMCID: PMC9939336 DOI: 10.3760/cma.j.issn.0253-2727.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
6
|
Li ACW, Dong C, Tay ST, Ananthakrishnan A, Ma KSK. Vedolizumab for acute gastrointestinal graft-versus-host disease: A systematic review and meta-analysis. Front Immunol 2022; 13:1025350. [PMID: 36439135 PMCID: PMC9692080 DOI: 10.3389/fimmu.2022.1025350] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/26/2022] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To determine the safety and efficacy of vedolizumab for the prophylaxis and treatment of gastrointestinal involvement of acute graft-versus-host disease (GVHD) (GI-aGVHD). METHODS Literature search within PubMed, EMBASE, Web of Science, and Cochrane Library for observational studies and clinical trials that evaluated the effect of vedolizumab on GI-aGVHD was done through 17 May 2022. A bivariate and random-effect meta-analysis derived the pooled observational percentages and pooled risk ratios (RRs) from baseline of primary endpoints including overall response, complete response, mortality, and adverse events. RESULTS There was a total of 122 participants in eight eligible studies, including one study on the prophylactic use of vedolizumab and seven studies on vedolizumab for the treatment of GI-aGVHD. Of seven studies that reported details on baseline grades of GI-aGVHD, a total of 47 patients (47.95%) were of stage 4, 31 patients (31.63%) were of stage 3, 10 patients (10.2%) were of stage 2, and 10 patients (10.2%) were of stage 1. The use of vedolizumab for the treatment of GI-aGVHD yielded a significantly improved objective response rate (ORR) at 14 days (pooled ORR = 60.53%, pooled RR = 14.14, 95% CI: 2.95-67.71), 28 days (pooled ORR = 50%, RR = 7.36, 95% CI = 2.14-25.37), and 12 months (pooled ORR = 76.92%, RR = 13.66, 95% CI = 3.5-53.35) from baseline. Likewise, the use of vedolizumab was followed by a significantly improved complete response (CR) at 12 months (pooled CR = 27.27%, RR = 5.50, 95% CI = 1.01-29.95), yet the CR at 14 days and 28 days did not reach statistical significance. Fifty-seven out of 87 (pooled overall survival, OS = 34.5%) and 46 out of 65 (pooled OS = 29.2%) patients expired at 6 and 12 months after the use of vedolizumab, respectively. Prophylactic use of vedolizumab was not associated with any specific type of reported adverse events, while patients with GI-aGVHD on vedolizumab presented with significantly increased risks of adverse events including infections (RR = 7.55) and impaired metabolism or nutritional complications (RR = 9.00). All analyses were of a low heterogeneity (all I-squares = 0%). CONCLUSION Vedolizumab was safe and effective for the prophylaxis and management of early grade GI-aGVHD. More clinical evidence is warranted to validate these findings. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=345584, identifier CRD42022345584.
Collapse
Affiliation(s)
- Allen Cheng-Wei Li
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Education, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chen Dong
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Soon-Tzeh Tay
- Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ashwin Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Kevin Sheng-Kai Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, United States
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
7
|
Hippen KL, Hefazi M, Larson JH, Blazar BR. Emerging translational strategies and challenges for enhancing regulatory T cell therapy for graft-versus-host disease. Front Immunol 2022; 13:926550. [PMID: 35967386 PMCID: PMC9366169 DOI: 10.3389/fimmu.2022.926550] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/27/2022] [Indexed: 02/03/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative therapy for many types of cancer. Genetic disparities between donor and host can result in immune-mediated attack of host tissues, known as graft versus host disease (GVHD), a major cause of morbidity and mortality following HSCT. Regulatory CD4+ T cells (Tregs) are a rare cell type crucial for immune system homeostasis, limiting the activation and differentiation of effector T cells (Teff) that are self-reactive or stimulated by foreign antigen exposure. Adoptive cell therapy (ACT) with Treg has demonstrated, first in murine models and now in patients, that prophylactic Treg infusion can also suppress GVHD. While clinical trials have demonstrated Treg reduce severe GVHD occurrence, several impediments remain, including Treg variability and practical need for individualized Treg production for each patient. Additionally, there are challenges in the use of in vitro expansion techniques and in achieving in vivo Treg persistence in context of both immune suppressive drugs and in lymphoreplete patients being treated for GVHD. This review will focus on 3 main translational approaches taken to improve the efficacy of tTreg ACT in GVHD prophylaxis and development of treatment options, following HSCT: genetic modification, manipulating TCR and cytokine signaling, and Treg production protocols. In vitro expansion for Treg ACT presents a multitude of approaches for gene modification to improve efficacy, including: antigen specificity, tissue targeting, deletion of negative regulators/exhaustion markers, resistance to immunosuppressive drugs common in GVHD treatment. Such expansion is particularly important in patients without significant lymphopenia that can drive Treg expansion, enabling a favorable Treg:Teff ratio in vivo. Several potential therapeutics have also been identified that enhance tTreg stability or persistence/expansion following ACT that target specific pathways, including: DNA/histone methylation status, TCR/co-stimulation signaling, and IL-2/STAT5 signaling. Finally, this review will discuss improvements in Treg production related to tissue source, Treg subsets, therapeutic approaches to increase Treg suppression and stability during tTreg expansion, and potential for storing large numbers of Treg from a single production run to be used as an off-the-shelf infusion product capable of treating multiple recipients.
Collapse
Affiliation(s)
- Keli L. Hippen
- University of Minnesota Cancer Center and the Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, Minneapolis, MN, United States
| | - Mehrdad Hefazi
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Jemma H. Larson
- University of Minnesota Cancer Center and the Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, Minneapolis, MN, United States
| | - Bruce R. Blazar
- University of Minnesota Cancer Center and the Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, Minneapolis, MN, United States
| |
Collapse
|
8
|
Song Q, Nasri U, Nakamura R, Martin PJ, Zeng D. Retention of Donor T Cells in Lymphohematopoietic Tissue and Augmentation of Tissue PD-L1 Protection for Prevention of GVHD While Preserving GVL Activity. Front Immunol 2022; 13:907673. [PMID: 35677056 PMCID: PMC9168269 DOI: 10.3389/fimmu.2022.907673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (Allo-HCT) is a curative therapy for hematological malignancies (i.e., leukemia and lymphoma) due to the graft-versus-leukemia (GVL) activity mediated by alloreactive T cells that can eliminate residual malignant cells and prevent relapse. However, the same alloreactive T cells can cause a serious side effect, known as graft-versus-host disease (GVHD). GVHD and GVL occur in distinct organ and tissues, with GVHD occurring in target organs (e.g., the gut, liver, lung, skin, etc.) and GVL in lympho-hematopoietic tissues where hematological cancer cells primarily reside. Currently used immunosuppressive drugs for the treatment of GVHD inhibit donor T cell activation and expansion, resulting in a decrease in both GVHD and GVL activity that is associated with cancer relapse. To prevent GVHD, it is important to allow full activation and expansion of alloreactive T cells in the lympho-hematopoietic tissues, as well as prevent donor T cells from migrating into the GVHD target tissues, and tolerize infiltrating T cells via protective mechanisms, such as PD-L1 interacting with PD-1, in the target tissues. In this review, we will summarize major approaches that prevent donor T cell migration into GVHD target tissues and approaches that augment tolerization of the infiltrating T cells in the GVHD target tissues while preserving strong GVL activity in the lympho-hematopoietic tissues.
Collapse
Affiliation(s)
- Qingxiao Song
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Fujian Medical University Center of Translational Hematology, Fujian Institute of Hematology, and Fujian Medical University Union Hospital, Fuzhou, China
| | - Ubaydah Nasri
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States
| | - Ryotaro Nakamura
- Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States
| | - Paul J Martin
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA, United States
| | - Defu Zeng
- Arthur D. Riggs Diabetes and Metabolism Research Institute, The Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, Unites States.,Hematologic Malignancies and Stem Cell Transplantation Institute, City of Hope National Medical Center, Duarte, CA, Unites States
| |
Collapse
|
9
|
Challenges and opportunities targeting mechanisms of epithelial injury and recovery in acute intestinal graft-versus-host disease. Mucosal Immunol 2022; 15:605-619. [PMID: 35654837 PMCID: PMC9259481 DOI: 10.1038/s41385-022-00527-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/21/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
Despite advances in immunosuppressive prophylaxis and overall supportive care, gastrointestinal (GI) graft-versus-host disease (GVHD) remains a major, lethal side effect after allogeneic hematopoietic stem cell transplantation (allo-HSCT). It has become increasingly clear that the intestinal epithelium, in addition to being a target of transplant-related toxicity and GVHD, plays an important role in the onset of GVHD. Over the last two decades, increased understanding of the epithelial constituents and their microenvironment has led to the development of novel prophylactic and therapeutic interventions, with the potential to protect the intestinal epithelium from GVHD-associated damage and promote its recovery following insult. In this review, we will discuss intestinal epithelial injury and the role of the intestinal epithelium in GVHD pathogenesis. In addition, we will highlight possible approaches to protect the GI tract from damage posttransplant and to stimulate epithelial regeneration, in order to promote intestinal recovery. Combined treatment modalities integrating immunomodulation, epithelial protection, and induction of regeneration may hold the key to unlocking mucosal recovery and optimizing therapy for acute intestinal GVHD.
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW Graft-versus-host disease (GVHD) following hematopoietic cell transplant (HCT) has a significant impact on morbidity and mortality among recipients. Predicting the long-term outcomes at the time of diagnosis of GVHD or even after response to up-front therapy can be challenging and only has modest accuracy. With biomarkers available to help guide decision-making, the landscape of GVHD is evolving. RECENT FINDINGS Several acute GVHD biomarkers have been identified, with some better able to categorize patients based on their GVHD severity and potential for refractory disease than standard clinical staging or response criteria. SUMMARY Biomarkers are now being incorporated into the clinical trial design for both high and low-risk GVHD. These findings will likely impact how clinical care is delivered in the future as improved risk stratification has the potential to improve outcomes by providing individualized treatment plans for affected patients.
Collapse
Affiliation(s)
- Saara Kaviany
- Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Department of Pediatrics, Division of Hematology/Oncology, Nashville, Tennessee, USA
| | | |
Collapse
|
11
|
Ibrahimova A, Davies SM, Lane A, Jordan MB, Lake K, Litts B, Chaturvedi V, Owsley E, Myers KC, Nelson AS, Mehta PA, Marsh RA, Khandelwal P. α4β7 Integrin expression and blockade in pediatric and young adult gastrointestinal graft-versus-host disease. Pediatr Blood Cancer 2021; 68:e28968. [PMID: 33861521 DOI: 10.1002/pbc.28968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/04/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND We hypothesized that α4β7 integrin expression on effector memory T cells (TEMs) would be elevated in pediatric hematopoietic stem cell transplant (HSCT) patients before and at diagnosis of acute gastrointestinal graft-versus-host disease (GI GVHD) symptoms compared to patients without GVHD, and that clinical blockade of α4β7 integrin with vedolizumab would be effective in pediatric GI GVHD. METHODS We analyzed surface expression of α4β7 integrin on T cells from 48 pediatric allogeneic HSCT recipients from our biorepository with known clinical outcomes as follows: acute GI GVHD (n = 22), isolated skin GVHD (n = 12), and no GVHD (n = 14). T-cell analyses were performed 1 week before and at GVHD diagnosis in patients with GVHD, and day +30 after HSCT in patients without GVHD. We describe clinical outcomes of seven additional patients, different from above-described 48 patients, who received vedolizumab (anti-α4β7 integrin antibody) for the treatment of steroid-refractory acute GI GVHD. RESULTS Expression of α4β7 integrin on CD8+ TEMs was upregulated in patients with GI GVHD compared to the no GI GVHD (skin GVHD + no GVHD) group 1 week prior to clinical symptoms (p = .02) and at acute GI GVHD diagnosis (p = .05). Four of seven treated patients with clinical steroid-refractory acute GI GVHD were evaluable for response to vedolizumab. One patient had a complete response at day +28, while two had a partial response, and one had no response. No adverse effects directly attributable to vedolizumab were observed. CONCLUSION Our data suggest a rationale for the blockade of α4β7 integrin for acute GI GVHD management in children.
Collapse
Affiliation(s)
- Azada Ibrahimova
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Stella M Davies
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Lane
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael B Jordan
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kelly Lake
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Bridget Litts
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vijaya Chaturvedi
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Erika Owsley
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kasiani C Myers
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam S Nelson
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Parinda A Mehta
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rebecca A Marsh
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Pooja Khandelwal
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
12
|
A phase 2a randomized clinical trial of intravenous vedolizumab for the treatment of steroid-refractory intestinal acute graft-versus-host disease. Bone Marrow Transplant 2021; 56:2477-2488. [PMID: 34108672 PMCID: PMC8486663 DOI: 10.1038/s41409-021-01356-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 04/23/2021] [Accepted: 05/12/2021] [Indexed: 01/10/2023]
Abstract
Steroid-refractory (SR) acute graft-versus-host disease (aGvHD) remains a significant complication after allogeneic hematopoietic cell transplantation. Systemic corticosteroids are first-line therapy for aGvHD, but apart from ruxolitinib, there are no approved treatments for SR aGvHD. Vedolizumab is approved for treatment of ulcerative colitis and Crohn’s disease, and may be effective for treatment of SR intestinal aGvHD. We conducted a phase 2a trial (NCT02993783) to evaluate the clinical efficacy, tolerability, and safety of vedolizumab 300 and 600 mg for SR intestinal aGvHD. This study was terminated before full enrollment was completed because early results failed to demonstrate positive proof-of-concept in efficacy. Before termination, 17 participants had enrolled and an early response in intestinal aGvHD was observed in 11 and eight participants at days 15 and 28, respectively. All adverse events observed were consistent with those expected in a population with SR intestinal aGvHD. Overall, vedolizumab did not meet the primary efficacy endpoint (overall response at day 28), likely owing to premature study drug discontinuation, lack of efficacy, and the competing risks inherent with a population with advanced SR intestinal aGvHD. Nevertheless, this study provides valuable insights into the considerations needed when conducting studies in patients with SR intestinal aGvHD.
Collapse
|
13
|
Bäuerlein CA, Qureischi M, Mokhtari Z, Tabares P, Brede C, Jordán Garrote AL, Riedel SS, Chopra M, Reu S, Mottok A, Arellano-Viera E, Graf C, Kurzwart M, Schmiedgen K, Einsele H, Wölfl M, Schlegel PG, Beilhack A. A T-Cell Surface Marker Panel Predicts Murine Acute Graft-Versus-Host Disease. Front Immunol 2021; 11:593321. [PMID: 33584657 PMCID: PMC7880247 DOI: 10.3389/fimmu.2020.593321] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
Acute graft-versus-host disease (aGvHD) is a severe and often life-threatening complication of allogeneic hematopoietic cell transplantation (allo-HCT). AGvHD is mediated by alloreactive donor T-cells targeting predominantly the gastrointestinal tract, liver, and skin. Recent work in mice and patients undergoing allo-HCT showed that alloreactive T-cells can be identified by the expression of α4β7 integrin on T-cells even before manifestation of an aGvHD. Here, we investigated whether the detection of a combination of the expression of T-cell surface markers on peripheral blood (PB) CD8+ T-cells would improve the ability to predict aGvHD. To this end, we employed two independent preclinical models of minor histocompatibility antigen mismatched allo-HCT following myeloablative conditioning. Expression profiles of integrins, selectins, chemokine receptors, and activation markers of PB donor T-cells were measured with multiparameter flow cytometry at multiple time points before the onset of clinical aGvHD symptoms. In both allo-HCT models, we demonstrated a significant upregulation of α4β7 integrin, CD162E, CD162P, and conversely, a downregulation of CD62L on donor T-cells, which could be correlated with the development of aGvHD. Other surface markers, such as CD25, CD69, and CC-chemokine receptors were not found to be predictive markers. Based on these preclinical data from mouse models, we propose a surface marker panel on peripheral blood T-cells after allo-HCT combining α4β7 integrin with CD62L, CD162E, and CD162P (cutaneous lymphocyte antigens, CLA, in humans) to identify patients at risk for developing aGvHD early after allo-HCT.
Collapse
Affiliation(s)
- Carina A Bäuerlein
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany.,Graduate School of Life Sciences, Würzburg University, Würzburg, Germany
| | - Musga Qureischi
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany.,Graduate School of Life Sciences, Würzburg University, Würzburg, Germany
| | - Zeinab Mokhtari
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany
| | - Paula Tabares
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany
| | - Christian Brede
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany.,Graduate School of Life Sciences, Würzburg University, Würzburg, Germany
| | - Ana-Laura Jordán Garrote
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany.,Graduate School of Life Sciences, Würzburg University, Würzburg, Germany
| | - Simone S Riedel
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany.,Graduate School of Life Sciences, Würzburg University, Würzburg, Germany
| | - Martin Chopra
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany
| | - Simone Reu
- Institute of Pathology, Würzburg University, Würzburg, Germany
| | - Anja Mottok
- Institute of Pathology, Würzburg University, Würzburg, Germany
| | - Estibaliz Arellano-Viera
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany
| | - Carolin Graf
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany
| | - Miriam Kurzwart
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany
| | - Katharina Schmiedgen
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany
| | - Hermann Einsele
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Graduate School of Life Sciences, Würzburg University, Würzburg, Germany
| | - Matthias Wölfl
- Graduate School of Life Sciences, Würzburg University, Würzburg, Germany.,Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Paul-Gerhardt Schlegel
- Graduate School of Life Sciences, Würzburg University, Würzburg, Germany.,Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Andreas Beilhack
- Department of Medicine II, University Hospital of Würzburg, Würzburg, Germany.,Interdisciplinary Center for Clinical Research (IZKF), Würzburg University, Würzburg, Germany.,Graduate School of Life Sciences, Würzburg University, Würzburg, Germany
| |
Collapse
|
14
|
Vedolizumab for prevention of graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Blood Adv 2020; 3:4136-4146. [PMID: 31821456 DOI: 10.1182/bloodadvances.2019000893] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/31/2019] [Indexed: 12/21/2022] Open
Abstract
Acute graft-versus-host disease (aGVHD) remains a significant complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Vedolizumab could help prevent aGVHD by inhibiting the migration of both naive and activated lymphocytes into gut-associated lymphoid tissues and the lamina propria. We carried out a phase 1b, open-label, dose-finding study in adults undergoing allo-HSCT to evaluate the tolerability, safety, and pharmacokinetics of vedolizumab, and its effectiveness in reducing aGVHD. IV vedolizumab was administered on day -1, +13, and +42 with respect to allo-HSCT, starting at 75 mg and with dose escalation guided by tolerability and pharmacokinetics. A total of 24 participants was enrolled, and no dose-limiting toxicities were observed in either the 75-mg cohort (n = 3) or the dose-escalated 300-mg cohort (n = 21). Treatment-emergent adverse events related to vedolizumab occurred in 8 participants. Overall, 4 deaths occurred during the 12 months following allo-HSCT. No participants in the 75-mg cohort developed modified Glucksberg grade II to IV aGVHD by 100 days after allo-HSCT. Four participants (19.0%) in the 300-mg cohort developed grade II to IV aGVHD by 100 days after allo-HSCT, including 3 participants who developed stage 1 aGVHD of the lower-intestinal tract. Vedolizumab IV 300 mg was well tolerated as aGVHD prevention, and the incidence of overall and lower-intestinal aGVHD was low. These findings support further evaluation of vedolizumab in this patient population. This trial was registered at www.clinicaltrials.gov as #NCT02728895.
Collapse
|
15
|
Phase II trial of natalizumab with corticosteroids as initial treatment of gastrointestinal acute graft-versus-host disease. Bone Marrow Transplant 2020; 56:1006-1012. [PMID: 32895491 DOI: 10.1038/s41409-020-01049-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022]
Abstract
The α4ß7 integrin is upregulated on naive and memory T cell subsets in patients who subsequently develop gastrointestinal (GI) acute GVHD. Natalizumab (Tysabri®, Biogen Inc.) acts against the α4 subunit that mediates homing of lymphocytes to the GI tract. We initiated a phase II study of natalizumab with corticosteroids for initial treatment of acute GI GVHD. In total, 300 mg IV of natalizumab was given, with steroids initiated up to 3 days prior. Twenty-one subjects were treated, median age was 63 years (range 38-74), and 15 (71%) were male. Eighteen (86%) underwent RIC, 15 (71%) received MUD, and all received PBSCs. Overall GVHD at enrollment was grade II in 4 and grade III in 17. The primary endpoint, day 56 GVHD-free survival rate, was attained in 33.3%. The overall response rate at day 28 and 56 was 57% and 52%, respectively. Six of eight CRs were durable for 1 year. Five experienced toxicity possibly related to natalizumab and ten had infections before day 100. 2-year OS was 43% (95% CI 22-62%) and 2-year NRM was 52% (95% CI 29-71%). Natalizumab with corticosteroids as initial treatment of acute GI GVHD is safe, effective, and durable.
Collapse
|
16
|
Chen S, Zeiser R. Novel Biomarkers for Outcome After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:1854. [PMID: 33013836 PMCID: PMC7461883 DOI: 10.3389/fimmu.2020.01854] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/09/2020] [Indexed: 12/29/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a well-established curative treatment for various malignant hematological diseases. However, its clinical success is substantially limited by major complications including graft-vs.-host disease (GVHD) and relapse of the underlying disease. Although these complications are known to lead to significant morbidity and mortality, standardized pathways for risk stratification of patients undergoing allo-HSCT are lacking. Recent advances in the development of diagnostic and prognostic tools have allowed the identification of biomarkers in order to predict outcome after allo-HSCT. This review will provide a summary of clinically relevant biomarkers that have been studied to predict the development of acute GVHD, the responsiveness of affected patients to immunosuppressive treatment and the risk of non-relapse mortality. Furthermore, biomarkers associated with increased risk of relapse and subsequent mortality will be discussed.
Collapse
Affiliation(s)
- Sophia Chen
- Department of Immunology, Memorial Sloan Kettering Cancer Center, Sloan Kettering Institute, New York, NY, United States.,Department of Medicine I, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany.,Signalling Research Centres BIOSS and CIBSS - Centre for Integrative Biological Signalling Studies, University of Freiburg, Freiburg, Germany
| |
Collapse
|
17
|
DiMaggio E. Acute Graft-versus-Host Disease: Emerging Insights and Updates into Detection, Prevention, and Treatment. Pharmacotherapy 2020; 40:788-807. [PMID: 32530080 DOI: 10.1002/phar.2436] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute graft-versus-host disease remains a devastating complication following hematopoietic cell transplantation, resulting in increased morbidity and mortality. Vast research efforts continue to refine or develop new means of prediction, assessment, prevention, and treatment of this syndrome. Recent updates in acute graft-versus-host disease include more definitive guidance and definitions for its grading and diagnosis. Biomarker use is being incorporated into early stages following hematopoietic cell transplantation to aid in the detection and prediction of long-term outcomes. New preventive strategies under investigation include the use of vedolizumab or tocilizumab as upfront prophylaxis. Finally, although steroids remain the backbone of therapy once treatment is warranted, the efficacy of several agents including vedolizumab, tocilizumab, ruxolitinib, and α1 antitrypsin are being evaluated as potential therapeutic options.
Collapse
|
18
|
Zheng J, Taylor B, Dodge J, Stephans A, Zheng SG, Chen Q, Chen X. Radiation and host retinoic acid signaling promote the induction of gut-homing donor T cells after allogeneic hematopoietic stem cell transplantation. Am J Transplant 2020; 20:64-74. [PMID: 31207088 PMCID: PMC6918002 DOI: 10.1111/ajt.15501] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 06/06/2019] [Accepted: 06/08/2019] [Indexed: 01/25/2023]
Abstract
Intestinal graft-versus-host disease (GVHD) remains a devastating complication after allogeneic hematopoietic stem cell transplantation (HSCT). Although it has been well established that gut-tropic donor T cells expressing integrin α4β7 are required to cause intestinal damage, the factors that control the induction of this pathogenic T cell population remain to be identified. Retinoic acid (RA) plays an important role in inducing α4β7 expression on T cells. In this study, we showed that gene expression of retinaldehyde dehydrogenase, the key enzyme involved in RA biosynthesis, is significantly increased in the spleen and mesenteric lymph nodes (MLNs) of irradiated mice. In a C57BL/6-into-B6D2F1 allogeneic HSCT model, irradiation significantly increased the induction of α4β7+ -donor T cells in mesenteric lymph nodes and spleen. Furthermore, we found that the RA pathway modulates the ability of dendritic cells to imprint gut-homing specificity on alloreactive T cells. We also showed that host dendritic cell RA signaling influences GVHD risk. Our studies identified radiation and recipient RA signaling as 2 primary factors that dictate the magnitude of gut-homing donor T cell induction after allogeneic HSCT. Attenuating radiation-associated inflammation and modulating host RA signaling represent feasible strategies to mitigate intestinal GVHD by reducing gut-seeking pathogenic donor T cells.
Collapse
Affiliation(s)
- Jianwei Zheng
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA;,Department of Oncology, the Union Hospital Affiliated with Fujian Medical University, Fuzhou, Fujian, China
| | - Brian Taylor
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Joseph Dodge
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Allison Stephans
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Song Guo Zheng
- Division of Rheumatology and Immunology, Department of Internal Medicine, Ohio State University School of Medicine and Wexner Medical Center, Columbus, OH 43201
| | - Qiang Chen
- Department of Oncology, the Union Hospital Affiliated with Fujian Medical University, Fuzhou, Fujian, China
| | - Xiao Chen
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| |
Collapse
|
19
|
Fløisand Y, Lazarevic VL, Maertens J, Mattsson J, Shah NN, Zachée P, Taylor A, Akbari M, Quadri S, Parfionovas A, Chen YB. Safety and Effectiveness of Vedolizumab in Patients with Steroid-Refractory Gastrointestinal Acute Graft-versus-Host Disease: A Retrospective Record Review. Biol Blood Marrow Transplant 2019; 25:720-727. [PMID: 30468919 DOI: 10.1016/j.bbmt.2018.11.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/13/2018] [Indexed: 01/01/2023]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) can be curative in patients with hematologic malignancies but carries a significant risk of graft-versus-host disease (GVHD). There are no standard treatments for steroid-refractory (SR) gastrointestinal (GI) acute GVHD (aGVHD). This multicenter, international, retrospective medical record review aimed to evaluate the off-label use of vedolizumab, a gut-selective immunomodulator, for treating SR GI aGVHD. Data were collected from patients' medical records; criteria for extraction included no more than 1 allo-HCT and at least 1 dose of vedolizumab as treatment for SR GI aGVHD (ie, stage 1 to 4 GI aGVHD following ≥1 previous treatment regimen(s) containing ≥1 mg/kg methylprednisolone or equivalent). Descriptive analyses of response rate, overall survival (OS), and serious adverse effects (SAEs) were performed. Twenty-nine patients were identified from 7 sites who had received 1 to 10 doses of vedolizumab 300 mg i.v. (median 3 doses) as treatment for SR GI aGVHD. The overall response rate at 6 to 10 weeks after vedolizumab initiation was 64%, and OS at 6 months was 54%. There were 29 SAEs, including 12 infections; 3 SAEs were considered possibly related to vedolizumab, 2 of which were infections. Thirteen SAEs were fatal, 1 of which was possibly vedolizumab-related. There were 8 nonserious infections and 1 serious infection with confirmed GI origin in 8 patients; there was no apparent pattern in the timing of these infections relative to the initiation of vedolizumab treatment. Further data on the efficacy and safety of vedolizumab in this setting from prospective trials are needed.
Collapse
Affiliation(s)
- Yngvar Fløisand
- Department of Hematology, Oslo University Hospital, Oslo, Norway.
| | - Vladimir Lj Lazarevic
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johan Maertens
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Jonas Mattsson
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - Nirav N Shah
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pierre Zachée
- Hematology Service, ZNA Stuivenberg, Antwerp, Belgium
| | - Aliki Taylor
- Takeda Development Centre Europe Ltd, London, UK
| | - Mona Akbari
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts
| | - Syed Quadri
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts
| | | | - Yi-Bin Chen
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
20
|
Lupsa N, Érsek B, Horváth A, Bencsik A, Lajkó E, Silló P, Oszvald Á, Wiener Z, Reményi P, Mikala G, Masszi T, Buzás EI, Pós Z. Skin-homing CD8 + T cells preferentially express GPI-anchored peptidase inhibitor 16, an inhibitor of cathepsin K. Eur J Immunol 2018; 48:1944-1957. [PMID: 30365157 DOI: 10.1002/eji.201847552] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/07/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022]
Abstract
This study sought to identify novel CD8+ T cell homing markers by studying acute graft versus host disease (aGvHD), typically involving increased T cell homing to the skin and gut. FACS-sorted skin-homing (CD8β+ /CLA+ ), gut-homing (CD8β+ /integrinβ7+ ), and reference (CD8β+ /CLA- /integrinβ7- ) T cells were compared in patients affected by cutaneous and/or gastrointestinal aGVHD. Microarray analysis, qPCR, and flow cytometry revealed increased expression of peptidase inhibitor 16 (PI16) in skin-homing CD8+ T cells. Robust association of PI16 with skin homing was confirmed in all types of aGvHD and in healthy controls, too. PI16 was not observed on CLA+ leukocytes other than T cells. Induction of PI16 expression on skin-homing T cells occurred independently of vitamin D3. Among skin-homing T cells, PI16 expression was most pronounced in memory-like CD45RO+ /CD127+ /CD25+ /CD69- /granzyme B- cells. PI16 was confined to the plasma membrane, was GPI-anchored, and was lost upon restimulation of memory CD8+ T cells. Loss of PI16 occurred by downregulation of PI16 transcription, and not by Phospholipase C (PLC)- or Angiotensin-converting enzyme (ACE)-mediated shedding, or by protein recycling. Inhibitor screening and pull-down experiments confirmed that PI16 inhibits cathepsin K, but may not bind to other skin proteases. These data link PI16 to skin-homing CD8+ T cells, and raise the possibility that PI16 may regulate cutaneous cathepsin K.
Collapse
Affiliation(s)
- Nikolett Lupsa
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary.,Hungarian Academy of Sciences, Semmelweis University Immunoproteogenomics Extracellular Vesicle Research Group, Budapest, Hungary
| | - Barbara Érsek
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary.,Office for Research Groups Attached to Universities and Other Institutions, Hungarian Academy of Sciences, Budapest, Hungary
| | - Andor Horváth
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - András Bencsik
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Eszter Lajkó
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Pálma Silló
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - Ádám Oszvald
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Zoltán Wiener
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Péter Reményi
- Department of Hematology and Stem Cell Transplantation, St. Istvan and Saint Laszlo Hospital, Budapest, Hungary
| | - Gábor Mikala
- Department of Hematology and Stem Cell Transplantation, St. Istvan and Saint Laszlo Hospital, Budapest, Hungary
| | - Tamás Masszi
- Department of Hematology and Stem Cell Transplantation, St. Istvan and Saint Laszlo Hospital, Budapest, Hungary.,3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - Edit I Buzás
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary.,Hungarian Academy of Sciences, Semmelweis University Immunoproteogenomics Extracellular Vesicle Research Group, Budapest, Hungary
| | - Zoltán Pós
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| |
Collapse
|
21
|
Nomura S, Ishii K, Fujita S, Nakaya A, Satake A, Ito T. Associations between acute GVHD-related biomarkers and endothelial cell activation after allogeneic hematopoietic stem cell transplantation. Transpl Immunol 2017; 43-44:27-32. [PMID: 28687251 DOI: 10.1016/j.trim.2017.06.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Revised: 06/26/2017] [Accepted: 06/28/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hematopoietic stem cell transplantation (HSCT) can cause serious transplant-related complications such as graft-versus-host disease (GVHD). Acute GVHD (aGVHD) has been diagnosed by clinical manifestations, laboratory data and pathological effects until now, but recently the discovery of specific biomarkers such as suppression of tumorigenicity 2 (ST2), elafin and regenerating islet-derived 3α (REG3α) is challenging this approach. METHODS We investigated the expression of aGVHD-related markers (regulated on activation normal T-cell expressed and secretes: RANTES, elafin, REG3α and ST2) and endothelial cell activation markers (soluble vascular cell adhesion molecule: sVCAM-1 and plasminogen activator inhibitor: PAI-1) in patients undergoing allogeneic HSCT. Additionally, we studied the effects of recombinant soluble thrombomodulin (rTM) on the expression of these markers. Our study cohort included 225 patients who underwent allogeneic HSCT at several institutions in Japan. RESULTS RANTES, sVCAM-1, PAI-1, elafin, REG3α and ST2 exhibited significant increases in patients not receiving rTM after HSCT. When we examined patients with confirmed complications, the frequencies of aGVHD and VOD were significantly lower in the rTM-treated group. In addition, aGVHD-related biomarkers such as elafin, REG3α, and ST2 were elevated significantly in patients with aGVHD. CONCLUSION Our findings suggest that endothelial cell activation might be linked to aGVHD, and that rTM might act to prevent aGVHD, at least in part, through its effect on endothelial cells.
Collapse
|
22
|
McDonald GB, Tabellini L, Storer BE, Martin PJ, Lawler RL, Rosinski SL, Schoch HG, Hansen JA. Predictive Value of Clinical Findings and Plasma Biomarkers after Fourteen Days of Prednisone Treatment for Acute Graft-versus-host Disease. Biol Blood Marrow Transplant 2017; 23:1257-1263. [PMID: 28478120 DOI: 10.1016/j.bbmt.2017.04.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 04/29/2017] [Indexed: 11/30/2022]
Abstract
We examined the hypothesis that plasma biomarkers and concomitant clinical findings after initial glucocorticoid therapy can accurately predict failure of graft-versus-host-disease (GVHD) treatment and mortality. We analyzed plasma samples and clinical data in 165 patients after 14 days of glucocorticoid therapy and used logistic regression and areas under receiver-operating characteristic curves (AUC) to evaluate associations with treatment failure and nonrelapse mortality (NRM). Initial treatment of GVHD was unsuccessful in 49 patients (30%). For predicting GVHD treatment failure, the best clinical combination (total serum bilirubin and skin GVHD stage: AUC, .70) was competitive with the best biomarker combination (T cell immunoglobulin and mucin domain 3 [TIM3] and [interleukin 1 receptor family encoded by the IL1RL1 gene, ST2]: AUC, .73). The combination of clinical features and biomarker results offered only a slight improvement (AUC, .75). For predicting NRM at 1 year, the best clinical predictor (total serum bilirubin: AUC, .81) was competitive with the best biomarker combination (TIM3 and soluble tumor necrosis factor receptor-1 [sTNFR1]: AUC, .85). The combination offered no improvement (AUC, .85). Infection was the proximate cause of death in virtually all patients. We conclude that after 14 days of glucocorticoid therapy, clinical findings (serum bilirubin, skin GVHD) and plasma biomarkers (TIM3, ST2, sTNFR1) can predict failure of GVHD treatment and NRM. These biomarkers reflect counter-regulatory mechanisms and provide insight into the pathophysiology of GVHD reactions after glucocorticoid treatment. The best predictive models, however, exhibit inadequate positive predictive values for identifying high-risk GVHD cohorts for investigational trials, as only a minority of patients with high-risk GVHD would be identified and most patients would be falsely predicted to have adverse outcomes.
Collapse
Affiliation(s)
- George B McDonald
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Laura Tabellini
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Barry E Storer
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Biostatistics, University of Washington School of Medicine, Seattle, Washington
| | - Paul J Martin
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Richard L Lawler
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Steven L Rosinski
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - H Gary Schoch
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John A Hansen
- Division of Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
23
|
de Melo KM, Unger S, Keller B, Gutenberger S, Stumpf I, Goldacker S, Warnatz K. Increase of circulating α4β7 + conventional memory CD4 and regulatory T cells in patients with common variable immunodeficiency (CVID). Clin Immunol 2017; 180:80-83. [PMID: 28323147 DOI: 10.1016/j.clim.2017.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/15/2017] [Accepted: 03/16/2017] [Indexed: 01/04/2023]
Abstract
This study investigated whether circulating α4β7+ expressing T cells could serve as a potential marker for gastrointestinal (GI) disease activity in patients with CVID. The analysis of α4β7+ T cells in the peripheral blood of 36 patients and 22 healthy donors (HD) revealed increased percentages of α4β7+ conventional memory CD4 T cells and Tregs, but not among CD8 T-cell populations in patients with CVID compared to HD. No differences between patients with and without chronic or acute GI symptoms were observed. EUROClass smB- and 21lo patients, had higher percentages of α4β7+ memory CD4 T cells compared to HD and smB+ or 21norm patients, respectively. In summary, the detection of α4β7+ T cells in the peripheral blood did not correlate with active or chronic gastrointestinal disease. The increase of these cells in smB- and 21lo patients adds another piece to the immune dysregulation observed in these patients.
Collapse
Affiliation(s)
- Karina Mescouto de Melo
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Susanne Unger
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Baerbel Keller
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Sylvia Gutenberger
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Ina Stumpf
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Sigune Goldacker
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Klaus Warnatz
- Center for Chronic Immunodeficiency (CCI), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| |
Collapse
|
24
|
Hartwell MJ, Özbek U, Holler E, Renteria AS, Major-Monfried H, Reddy P, Aziz M, Hogan WJ, Ayuk F, Efebera YA, Hexner EO, Bunworasate U, Qayed M, Ordemann R, Wölfl M, Mielke S, Pawarode A, Chen YB, Devine S, Harris AC, Jagasia M, Kitko CL, Litzow MR, Kröger N, Locatelli F, Morales G, Nakamura R, Reshef R, Rösler W, Weber D, Wudhikarn K, Yanik GA, Levine JE, Ferrara JL. An early-biomarker algorithm predicts lethal graft-versus-host disease and survival. JCI Insight 2017; 2:e89798. [PMID: 28194439 DOI: 10.1172/jci.insight.89798] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND. No laboratory test can predict the risk of nonrelapse mortality (NRM) or severe graft-versus-host disease (GVHD) after hematopoietic cellular transplantation (HCT) prior to the onset of GVHD symptoms. METHODS. Patient blood samples on day 7 after HCT were obtained from a multicenter set of 1,287 patients, and 620 samples were assigned to a training set. We measured the concentrations of 4 GVHD biomarkers (ST2, REG3α, TNFR1, and IL-2Rα) and used them to model 6-month NRM using rigorous cross-validation strategies to identify the best algorithm that defined 2 distinct risk groups. We then applied the final algorithm in an independent test set (n = 309) and validation set (n = 358). RESULTS. A 2-biomarker model using ST2 and REG3α concentrations identified patients with a cumulative incidence of 6-month NRM of 28% in the high-risk group and 7% in the low-risk group (P < 0.001). The algorithm performed equally well in the test set (33% vs. 7%, P < 0.001) and the multicenter validation set (26% vs. 10%, P < 0.001). Sixteen percent, 17%, and 20% of patients were at high risk in the training, test, and validation sets, respectively. GVHD-related mortality was greater in high-risk patients (18% vs. 4%, P < 0.001), as was severe gastrointestinal GVHD (17% vs. 8%, P < 0.001). The same algorithm can be successfully adapted to define 3 distinct risk groups at GVHD onset. CONCLUSION. A biomarker algorithm based on a blood sample taken 7 days after HCT can consistently identify a group of patients at high risk for lethal GVHD and NRM. FUNDING. The National Cancer Institute, American Cancer Society, and the Doris Duke Charitable Foundation.
Collapse
Affiliation(s)
| | - Umut Özbek
- Biostatistics Shared Resource Facility, TischCancer Institute, the Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ernst Holler
- Blood and Marrow Transplantation Program, University of Regensburg, Regensburg, Germany
| | - Anne S Renteria
- Tisch Cancer Institute, the Icahn School of Medicine at Mount Sinai
| | | | - Pavan Reddy
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Mina Aziz
- Tisch Cancer Institute, the Icahn School of Medicine at Mount Sinai
| | - William J Hogan
- Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center, Hamburg-Eppendorf, Germany
| | - Yvonne A Efebera
- Blood and Marrow Transplantation Program, Ohio State University, Columbus, Ohio, USA
| | - Elizabeth O Hexner
- Blood and Marrow Transplantation Program, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Udomsak Bunworasate
- Blood and Marrow Transplantation Program, Chulalongkorn University, Bangkok, Thailand
| | - Muna Qayed
- Pediatric Blood and Marrow Transplantation Program, Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rainer Ordemann
- Blood and Marrow Transplantation Program, University Hospital TU Dresden, Dresden, Germany
| | - Matthias Wölfl
- Pediatric Blood and Marrow Transplantation Program, Children's Hospital
| | - Stephan Mielke
- Blood and Marrow Transplantation Program, University of Würzburg, Würzburg, Germany
| | - Attaphol Pawarode
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan, USA
| | - Yi-Bin Chen
- Bone Marrow Transplantation Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Steven Devine
- Blood and Marrow Transplantation Program, Ohio State University, Columbus, Ohio, USA
| | - Andrew C Harris
- Blood and Marrow Transplantation Program, University of Utah, Salt Lake City, Utah, USA
| | | | - Carrie L Kitko
- Pediatric Blood and Marrow Transplantation Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark R Litzow
- Blood and Marrow Transplantation Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center, Hamburg-Eppendorf, Germany
| | - Franco Locatelli
- Pediatric Blood and Marrow Transplantation Program, Ospedale Pediatrico Bambino Gesu, Rome, Italy
| | - George Morales
- Tisch Cancer Institute, the Icahn School of Medicine at Mount Sinai
| | - Ryotaro Nakamura
- Hematology and Hematopoietic Cell Transplantation, City of Hope Medical Center, Duarte, California, USA
| | - Ran Reshef
- Blood and Marrow Transplantation Program, Columbia University Medical Center, New York, New York, USA
| | - Wolf Rösler
- Department of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen-Nuremburg, Erlangen, Germany
| | - Daniela Weber
- Blood and Marrow Transplantation Program, University of Regensburg, Regensburg, Germany
| | - Kitsada Wudhikarn
- Blood and Marrow Transplantation Program, Chulalongkorn University, Bangkok, Thailand
| | - Gregory A Yanik
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, Michigan, USA
| | - John E Levine
- Tisch Cancer Institute, the Icahn School of Medicine at Mount Sinai
| | - James Lm Ferrara
- Tisch Cancer Institute, the Icahn School of Medicine at Mount Sinai
| |
Collapse
|
25
|
Kotsiou E, Gribben JG, Davies JK. Allospecific Tregs Expanded After Anergization Remain Suppressive in Inflammatory Conditions but Lack Expression of Gut-homing Molecules. Mol Ther 2016; 24:1126-1134. [PMID: 27049761 PMCID: PMC4923329 DOI: 10.1038/mt.2016.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/16/2016] [Indexed: 11/09/2022] Open
Abstract
Cell therapy with antigen-specific regulatory T-cells (Treg) has great potential to selectively control unwanted immune responses after allogeneic stem-cell or solid organ transplantation and in autoimmune diseases. Ex vivo allostimulation with costimulatory blockade (alloanergization) of human T-cells expands populations of alloantigen-specific Treg, providing a cellular strategy to control donor T-cell alloresponses causing graft-versus-host disease after allogeneic hematopoietic stem-cell transplantation. Crucially, it is not known if Treg expanded in this way are stable in proinflammatory conditions encountered after transplantation, or if they possess capacity to migrate to key target organs. Using an in vitro model to functionally characterize human Treg expanded after alloanergization, we now show that these cells remain potently allosuppressive in the presence of relevant exogenous inflammatory signals. Expanded allospecific Treg retained expression of molecules conferring migratory capacity to several organs but small intestine-specific chemotaxis was markedly impaired, in keeping with the preponderance of gut graft-versus-host disease in previous clinical studies using this strategy. Importantly, impaired gut-specific chemotaxis could be partially corrected by pharmacological treatment. These findings will facilitate more effective application of this cellular approach to limit T-cell alloresponses after hematopoietic stem-cell transplantation and the wider application of the strategy to other clinical settings.
Collapse
Affiliation(s)
- Eleni Kotsiou
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University London, London, UK
| | - John G Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University London, London, UK
| | - Jeff K Davies
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University London, London, UK.
| |
Collapse
|
26
|
Renteria AS, Levine JE, Ferrara JLM. Therapeutic targets and emerging treatment options in gastrointestinal acute graft-versus-host disease. Expert Opin Orphan Drugs 2016; 4:469-484. [PMID: 30057862 DOI: 10.1517/21678707.2016.1166949] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction Graft-versus-host disease (GVHD) continues to be the major lethal complication of allogeneic hematopoietic stem cell transplantation (HCT) but the standard of care, high dose steroids, has not changed in 40 years. Approximately 50% of GVHD patients will develop steroid refractory disease, typically involving the gastrointestinal (GI) tract, which has a very poor prognosis. Newly developed GVHD biomarker-based risk scores provide the first opportunity to treat patients at the onset of symptoms according to risk of steroid failure. Furthermore, improvements in our understanding of the pathobiology of GVHD, its different signaling pathways, involved cytokines, and the role of post-translational and epigenetic modifications, has identified new therapeutic targets for clinical trials. Areas covered This manuscript summarizes the pathophysiology, diagnosis, staging, current and new targeted therapies for GVHD, with an emphasis on GI GVHD. A literature search on PubMed was undertaken and the most relevant references included. Expert Opinion The standard treatment for GVHD, high dose steroids, offers less than optimal outcomes as well as significant toxicities. Better treatments, especially for GI GVHD, are needed to reduce non-relapse mortality after allogeneic HCT. The identification of high risk patients through a biomarker-defined scoring system offers a personalized approach to a disease that still requires significant research attention.
Collapse
Affiliation(s)
- Anne S Renteria
- Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John E Levine
- Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James L M Ferrara
- Hematologic Malignancies Translational Research Center, Blood and Marrow Transplantation Program, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
27
|
Intestinal barrier loss as a critical pathogenic link between inflammatory bowel disease and graft-versus-host disease. Mucosal Immunol 2015; 8:720-30. [PMID: 25943273 DOI: 10.1038/mi.2015.40] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 04/08/2015] [Indexed: 02/04/2023]
Abstract
Compromised intestinal barrier function is a prominent feature of inflammatory bowel disease (IBD). However, links between intestinal barrier loss and disease extend much further, including documented associations with celiac disease, type I diabetes, rheumatoid arthritis, and multiple sclerosis. Intestinal barrier loss has also been proposed to have a critical role in the pathogenesis of graft-versus-host disease (GVHD), a serious, potentially fatal consequence of hematopoietic stem cell transplantation. Experimental evidence has begun to support this view, as barrier loss and its role in initiating and establishing a pathogenic inflammatory cycle in GVHD is emerging. Here we discuss similarities between IBD and GVHD, mechanisms of intestinal barrier loss in these diseases, and the crosstalk between barrier loss and the immune system, with a special focus on natural killer (NK) cells. Unanswered questions and future research directions on the topic are discussed along with implications for treatment.
Collapse
|
28
|
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.
Collapse
Affiliation(s)
- Sophie Paczesny
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
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.
Collapse
|
30
|
Depletion of host CCR7(+) dendritic cells prevented donor T cell tissue tropism in anti-CD3-conditioned recipients. Biol Blood Marrow Transplant 2014; 20:920-8. [PMID: 24691220 DOI: 10.1016/j.bbmt.2014.03.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 03/25/2014] [Indexed: 11/23/2022]
Abstract
We reported previously that anti-CD3 mAb treatment before hematopoietic cell transplantation (HCT) prevented graft-versus-host disease (GVHD) and preserved graft-versus-leukemia (GVL) effects in mice. These effects were associated with downregulated donor T cell expression of tissue-specific homing and chemokine receptors, marked reduction of donor T cell migration into GVHD target tissues, and deletion of CD103(+) dendritic cells (DCs) in mesenteric lymph nodes (MLN). MLN CD103(+) DCs and peripheral lymph node (PLN) DCs include CCR7(+) and CCR7(-) subsets, but the role of these DC subsets in regulating donor T cell expression of homing and chemokine receptors remain unclear. Here, we show that recipient CCR7(+), but not CCR7(-), DCs in MLN induced donor T cell expression of gut-specific homing and chemokine receptors in a retinoid acid-dependent manner. CCR7 regulated activated DC migration from tissue to draining lymph node, but it was not required for the ability of DCs to induce donor T cell expression of tissue-specific homing and chemokine receptors. Finally, anti-CD3 treatment depleted CCR7(+) but not CCR7(-) DCs by inducing sequential expansion and apoptosis of CCR7(+) DCs in MLN and PLN. Apoptosis of CCR7(+) DCs was associated with DC upregulation of Fas expression and natural killer cell but not T, B, or dendritic cell upregulation of FasL expression in the lymph nodes. These results suggest that depletion of CCR7(+) host-type DCs, with subsequent inhibition of donor T cell migration into GVHD target tissues, can be an effective approach in prevention of acute GVHD and preservation of GVL effects.
Collapse
|
31
|
Comprehensive assessment of HIV target cells in the distal human gut suggests increasing HIV susceptibility toward the anus. J Acquir Immune Defic Syndr 2013; 63:263-71. [PMID: 23392465 DOI: 10.1097/qai.0b013e3182898392] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Prevention of rectal HIV transmission is a high-priority goal for vaccines and topical microbicides because a large fraction of HIV transmissions occurs rectally. Yet, little is known about the specific target-cell milieu in the human rectum other than inferences made from the colon. METHODS We conducted a comprehensive comparative in situ fluorescence study of HIV target cells (CCR5-expressing T cells, macrophages, and putative dendritic cells) at 4 and 30 cm proximal of the anal canal in 29 healthy individuals, using computerized analysis of digitized combination stains. RESULTS Most strikingly, we find that more than 3 times as many CD68 macrophages express the HIV coreceptor CCR5 in the rectum than in the colon (P = 0.0001), and as such rectal macrophages seem biologically closer to the HIV-susceptible CCR5 phenotype in the vagina than the mostly HIV-resistant CCR5 phenotype in the colon. Putative CD209 dendritic cells are generally enriched in the colon compared with the rectum (P = 0.0004), though their CCR5 expression levels are similar in both compartments. CD3 T-cell densities and CCR5 expression levels are comparable in the colon and rectum. CONCLUSIONS Our study establishes the target-cell environment for HIV infection in the human distal gut and demonstrates in general terms that the colon and rectum are immunologically distinct anatomical compartments. Greater expression of CCR5 on rectal macrophages suggests that the most distal sections of the gut may be especially vulnerable to HIV infection. Our findings also emphasize that caution should be exercised when extrapolating data obtained from colon tissues to the rectum.
Collapse
|
32
|
Bäuerlein CA, Riedel SS, Baker J, Brede C, Garrote ALJ, Chopra M, Ritz M, Beilhack GF, Schulz S, Zeiser R, Schlegel PG, Einsele H, Negrin RS, Beilhack A. A diagnostic window for the treatment of acute graft-versus-host disease prior to visible clinical symptoms in a murine model. BMC Med 2013; 11:134. [PMID: 23692886 PMCID: PMC3665617 DOI: 10.1186/1741-7015-11-134] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 04/19/2013] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Acute graft-versus-host disease (aGVHD) poses a major limitation for broader therapeutic application of allogeneic hematopoietic cell transplantation (allo-HCT). Early diagnosis of aGVHD remains difficult and is based on clinical symptoms and histopathological evaluation of tissue biopsies. Thus, current aGVHD diagnosis is limited to patients with established disease manifestation. Therefore, for improved disease prevention it is important to develop predictive assays to identify patients at risk of developing aGVHD. Here we address whether insights into the timing of the aGVHD initiation and effector phases could allow for the detection of migrating alloreactive T cells before clinical aGVHD onset to permit for efficient therapeutic intervention. METHODS Murine major histocompatibility complex (MHC) mismatched and minor histocompatibility antigen (miHAg) mismatched allo-HCT models were employed to assess the spatiotemporal distribution of donor T cells with flow cytometry and in vivo bioluminescence imaging (BLI). Daily flow cytometry analysis of peripheral blood mononuclear cells allowed us to identify migrating alloreactive T cells based on homing receptor expression profiles. RESULTS We identified a time period of 2 weeks of massive alloreactive donor T cell migration in the blood after miHAg mismatch allo-HCT before clinical aGVHD symptoms appeared. Alloreactive T cells upregulated α4β7 integrin and P-selectin ligand during this migration phase. Consequently, targeted preemptive treatment with rapamycin, starting at the earliest detection time of alloreactive donor T cells in the peripheral blood, prevented lethal aGVHD. CONCLUSIONS Based on this data we propose a critical time frame prior to the onset of aGVHD symptoms to identify alloreactive T cells in the peripheral blood for timely and effective therapeutic intervention.
Collapse
Affiliation(s)
- Carina A Bäuerlein
- Department of Medicine II, Würzburg University Clinics, Zinklesweg 10, Würzburg, D-97078, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
A critical role for the retinoic acid signaling pathway in the pathophysiology of gastrointestinal graft-versus-host disease. Blood 2013; 121:3970-80. [PMID: 23529927 DOI: 10.1182/blood-2012-08-445130] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Damage to the gastrointestinal tract during graft-versus-host disease (GVHD) is one of the major causes of morbidity and mortality in allogeneic hematopoietic stem cell transplant (HSCT) recipients. In the current study, we identified a critical role for the retinoic acid (RA) signaling pathway in the induction and propagation of gastrointestinal GVHD. The administration of exogenous RA significantly increased expression of the gut-homing molecules, CCR9 and α4β7, on donor T cells in mesenteric lymph nodes, and augmented the accumulation of proinflammatory CD4(+) and CD8(+) T cells within the gut mucosa, leading to a selective exacerbation of colonic GVHD and increased overall mortality. Conversely, depletion of RA in recipient mice by vitamin A deprivation resulted in a dramatic reduction of gut-homing molecule expression on donor T cells after HSCT. Significantly, absence of the RA receptor-α on donor T cells markedly attenuated the ability of these cells to cause lethal GVHD. This observation was attributable to a significant reduction in pathological damage within the colon. These findings identify an organ-specific role for RA in GVHD and provide evidence that blockade of the RA signaling pathway may represent a novel strategy for mitigating the severity of colonic GVHD.
Collapse
|
34
|
Engelhardt BG, Sengsayadeth SM, Jagasia M, Savani BN, Kassim AA, Lu P, Shyr Y, Yoder SM, Rock MT, Crowe JE. Tissue-specific regulatory T cells: biomarker for acute graft-vs-host disease and survival. Exp Hematol 2012; 40:974-982.e1. [PMID: 22885125 PMCID: PMC3611587 DOI: 10.1016/j.exphem.2012.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 07/19/2012] [Accepted: 08/05/2012] [Indexed: 12/13/2022]
Abstract
Regulatory T cells (Tregs) are a subset of CD4(+) T cells that are characterized by the expression of CD25 and Foxp3 and are capable of suppressing alloimmune responses. We assessed whether high frequencies of circulating skin or gut tissue-specific Tregs at engraftment could predict acute graft-vs-host disease (aGVHD) incidence and survival in a cohort of hematopoietic cell transplant (HCT) recipients. Tregs were analyzed at engraftment in 74 patients receiving HCT. Treg skin-homing (CLA(+)) or gut-homing (α(4)β(7)(+)) subsets were identified by flow cytometry, and patients were divided into high CLA(+) Tregs or high α(4)β(7)(+) Tregs groups, using the 75(th) percentile of tissue-specific Treg percentages as a threshold. At day +100 post-HCT, the cumulative incidence of any stage skin or gut aGVHD was significantly lower in those patients with high CLA(+) Tregs or high α(4)β(7)(+) Tregs at engraftment, respectively (high CLA(+) Tregs, 24.0% vs low CLA(+) Tregs, 55.1%; p = 0.011 for skin aGVHD or high α(4)β(7)(+) Tregs, 47.3% vs low α(4)β(7)(+) Tregs, 74.5%; p = 0.029 for gut aGVHD). The 2-year probabilities of overall survival and nonrelapse mortality were 73.4% and 7.5% among patients with high frequencies of tissue-specific Tregs vs 49.4% and 36.1% for those with both low CLA(+) Tregs and low α(4)β(7)(+) Tregs (p = 0.039, p = 0.010). These results suggest that a threshold value for CLA(+) or α(4)β(7)(+) Tregs could be used to predict important HCT outcomes, and to direct the rationale use of tissue-specific pre-emptive therapies to decrease clinical aGVHD and improve HCT survival.
Collapse
Affiliation(s)
- Brian G. Engelhardt
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Madan Jagasia
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bipin N. Savani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adetola A. Kassim
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pengcheng Lu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yu Shyr
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandra M. Yoder
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael T. Rock
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James E. Crowe
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
35
|
Expression of α4β7 integrin on memory CD8(+) T cells at the presentation of acute intestinal GVHD. Bone Marrow Transplant 2012; 48:598-603. [PMID: 23042495 DOI: 10.1038/bmt.2012.191] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute intestinal GVHD remains a major source of morbidity after allogeneic hematopoietic cell transplantation (HCT). α4β7 integrin is a cell surface molecule that mediates lymphocyte trafficking to intestinal tissue. In this analysis, peripheral blood was collected at the time of presentation of symptoms of acute GVHD and before any treatment. In all, 45 samples were collected and divided into three groups on the basis of subsequent evaluation: intestinal GVHD (n=15), skin GVHD (n=20) and no GVHD (n=10). Two patients developed intestinal GVHD after DLI. The no-GVHD group comprised 10 patients who presented with suspicious symptoms, but evaluation yielded other etiologies. Analysis by flow cytometry showed that intestinal GVHD patients had a significantly higher percentage of α4β7 integrin-expressing memory CD8(+) T cells (median 7.69%; lower and upper quartiles, 1.06% and 11.64%, respectively) compared with patients with skin GVHD (1.26%; 0.57% and 2.49%) and no GVHD (0.96%; 0.44% and 1.85%), P=0.03. No differences were found in α4β7 expression in any CD4(+) T-cell subsets or naive CD8(+) T cells. This study adds to the evidence that α4β7 integrin is involved in lymphocyte trafficking in acute intestinal GVHD.
Collapse
|
36
|
Chen YB, Cutler CS. Biomarkers for acute GVHD: can we predict the unpredictable? Bone Marrow Transplant 2012; 48:755-60. [PMID: 22863728 DOI: 10.1038/bmt.2012.143] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Acute GVHD remains an important complication after allogeneic hematopoietic cell transplantation (HCT). Many efforts have been devoted to identifying potential noninvasive peripheral blood biomarkers to help improve the diagnosis or management of acute GVHD while avoiding invasive tissue biopsies. Early attempts to identify biomarkers focused on inflammatory cytokines, especially IL-2 or TNF-α, however, both of these and others were not specific for GVHD, often being elevated in the setting of generalized inflammation, accompanying other major complications of HCT as well. More recent efforts have focused on additional cytokines and other cell-surface molecules, which function in leukocyte trafficking and activation with the hope that these can also serve as targets for novel therapeutic approaches. Modern proteomic methods have allowed the screening of large numbers of patient samples and yielded several novel candidate biomarkers, including elafin and reg3α, which may not be directly involved in the immunological pathogenesis of GVHD, but may be unique biomarkers for end-organ injury. Combining these new molecules with traditionally identified cytokines to form an acute GVHD biomarker panel has recently shown the ability to predict outcomes in patients who develop acute GVHD. The ultimate goals of identifying a specific biomarker are to refine diagnosis, guide therapy and develop risk-adapted approaches in order to better treat patients and improve outcomes after allogeneic HCT. These approaches include differential treatment for patients who develop acute GVHD with a high-risk biomarker profile as well as pre-emptive therapy in patients after HCT prior to the development of symptoms. With the recent progress summarized below, these goals may soon be realized.
Collapse
Affiliation(s)
- Y-B Chen
- Division of Hematology/Oncology, Bone Marrow Transplant Unit, Massachusetts General Hospital, Boston, MA 02114, USA.
| | | |
Collapse
|
37
|
Spitzer TR, Dey BR, Chen YB, Attar E, Ballen KK. The expanding frontier of hematopoietic cell transplantation. CYTOMETRY PART B-CLINICAL CYTOMETRY 2012; 82:271-9. [PMID: 22865649 DOI: 10.1002/cyto.b.21034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 06/13/2012] [Accepted: 06/19/2012] [Indexed: 12/18/2022]
Abstract
Over the past several decades there has been a tremendous expansion of the indications for hematopoietic cell transplantation. This growth has been possible because of advances in supportive care, more effective graft versus host disease prophylaxis and the advent of reduced intensity conditioning regimens which have greatly reduced transplant related morbidity and allowed for the transplantation of older patients and patients with significant co-morbid disease. The role of flow cytometry in transplantation is crucial to both clinical care, for accuracy of diagnosis and monitoring of disease, and research. In this review, we highlight some of the important advances that have been made in the field, including the use of alternative donors for transplantation, novel therapies for the myeloid malignancies, which remain the prototype diseases for transplantation, and advances in diagnosis and treatment of graft versus host disease, which is the principal complication of allogeneic hematopoietic cell transplantation. Future directions in hematopoietic cell transplantation, particularly those that attempt to modulate the post-transplant cellular environment to favor separation of graft versus host disease from the graft versus tumor effects of the transplant are discussed.
Collapse
Affiliation(s)
- Thomas R Spitzer
- Department of Medicine, Bone Marrow Transplant Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
| | | | | | | | | |
Collapse
|
38
|
Engelhardt BG, Jagasia M, Savani BN, Bratcher NL, Greer JP, Jiang A, Kassim AA, Lu P, Schuening F, Yoder SM, Rock MT, Crowe JE. Regulatory T cell expression of CLA or α(4)β(7) and skin or gut acute GVHD outcomes. Bone Marrow Transplant 2011; 46:436-42. [PMID: 20577222 PMCID: PMC3217583 DOI: 10.1038/bmt.2010.127] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 03/18/2010] [Accepted: 04/13/2010] [Indexed: 11/09/2022]
Abstract
Regulatory T cells (Tregs) are a suppressive subset of CD4(+) T lymphocytes implicated in the prevention of acute GVHD (aGVHD) after allo-SCT (ASCT). To determine whether increased frequency of Tregs with a skin-homing (cutaneous lymphocyte Ag, CLA(+)) or a gut-homing (α(4)β(7)(+)) phenotype is associated with reduced risk of skin or gut aGVHD, respectively, we quantified circulating CLA(+) or α(4)β(7)(+) on Tregs at the time of neutrophil engraftment in 43 patients undergoing ASCT. Increased CLA(+) Tregs at engraftment was associated with the prevention of skin aGVHD (2.6 vs 1.7%; P=0.038 (no skin aGVHD vs skin aGVHD)), and increased frequencies of CLA(+) and α(4)β(7)(+) Tregs were negatively correlated with severity of skin aGVHD (odds ratio (OR), 0.67; 95% confidence interval (CI), 0.46-0.98; P=0.041) or gut aGVHD (OR, 0.93; 95% CI, 0.88-0.99; P=0.031), respectively. This initial report suggests that Treg tissue-homing subsets help to regulate organ-specific risk and severity of aGVHD after human ASCT. These results need to be validated in a larger, multicenter cohort.
Collapse
Affiliation(s)
- BG Engelhardt
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Jagasia
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - BN Savani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - NL Bratcher
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JP Greer
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - A Jiang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - AA Kassim
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - P Lu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - F Schuening
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - SM Yoder
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - MT Rock
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JE Crowe
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
39
|
Integrin alpha4beta7 is downregulated on the surfaces of simian immunodeficiency virus SIVmac239-infected cells. J Virol 2010; 84:6344-51. [PMID: 20410278 DOI: 10.1128/jvi.00430-10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Simian immunodeficiency virus (SIV) and human immunodeficiency virus (HIV) infection results in an early and enduring depletion of intestinal CD4(+) T cells. SIV and HIV bind integrin alpha4beta7, thereby facilitating infection of lymphocytes that home to the gut-associated lymphoid tissue (GALT). Using an ex vivo flow cytometry assay, we found that SIVmac239-infected cells expressed significantly lower levels of integrin alpha4beta7 than did uninfected cells. This finding suggested a potential viral effect on integrin alpha4beta7 expression. Using an in vitro model, we confirmed that integrin alpha4beta7 was downregulated on the surfaces of SIVmac239-infected cells. Further, modulation of integrin alpha4beta7 was dependent on de novo synthesis of viral proteins, but neither cell death, the release of a soluble factor, nor a change in activation state was involved. Downregulation of integrin alpha4beta7 may have an unappreciated role in the CD4 depletion of the mucosal-associated lymphoid compartments, susceptibility to superinfection, and/or immune evasion.
Collapse
|