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Herzog S, Shanley R, Holtan SG, MacMillan ML, Weisdorf DJ, El Jurdi N. Treatment-Responsive Acute Graft-versus-Host Disease after Post-Transplantation Cyclophosphamide-Based Prophylaxis: Incidence and Clinical Outcomes. Transplant Cell Ther 2024; 30:688.e1-688.e9. [PMID: 38734182 PMCID: PMC11223983 DOI: 10.1016/j.jtct.2024.05.007] [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: 03/12/2024] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Post-transplantation cyclophosphamide (PTCy) following hematopoietic cell transplantation (HCT) has emerged as standard of care for graft-versus-host disease (GVHD) prevention in adult patients without increasing malignant relapse. We previously defined acute GVHD (aGVHD) treatment response categories as corticosteroid-sensitive (SS), -dependent (SD), or -resistant (SR) based on response to first-line corticosteroids and reported their clinical outcomes following non-PTCy-based prophylaxis. More than one-third of patients developed aGVHD necessitating systemic therapy. Cases were predominantly SR, with a 14% overall incidence of SR aGVHD. The incidence and clinical outcomes of these 3 distinct aGVHD treatment response groups following PTCy-based prophylaxis have not been well described. The objective of this retrospective single-institution cohort study was to assess the incidence and clinical outcomes of SS, SD, and SR aGVHD following HCT with PTCy-based prophylaxis using a prophylactic regimen of PTCy, tacrolimus, and mycophenolate mofetil (MMF). We included 196 consecutive adult and pediatric patients undergoing allogeneic HCT for malignant and non-malignant disorders at the University of Minnesota between 2017 and 2021. Patients received PTCy on days +3 and +4 plus tacrolimus and MMF prophylaxis. Bone marrow and peripheral blood stem cell graft sources and related and unrelated donors were included. Recipients received myeloablative or reduced-intensity conditioning regimens. Of the 196 allografts, 54 (28%) developed aGVHD before day +180, with a median time to onset of 50 days (interquartile range, 34 to 71 days). Of those, 32 patients (16% overall) developed maximum grade II-III aGVHD necessitating systemic corticosteroids, with the following response: 13 SS (41%), 10 SD (31%), and 9 SR (28%). The overall incidence of SR aGVHD was 4.6%. Only 12 patients (6%) developed maximum grade III aGVHD, and none had grade IV aGVHD. The 2-year overall survival analyzed from 80 days after initiation of systemic treatment was similar in the SS and SD groups (77 and 75%, respectively), comparable to those without aGVHD (81%), and was lowest in the SR group (20%), with GVHD the primary cause of death. Nonrelapse mortality was highest in the SR group. MN high-risk and higher GVHD grade at onset were risk factors for developing SR aGVHD. Overall, we report a low incidence (16%) of aGVHD requiring systemic corticosteroids with PTCy-based prophylaxis. aGVHD cases were predominantly SS aGVHD, with lower incidences of SD and SR aGVHD. Our findings suggest that PTCy-based prophylaxis reduces the rate of treatment-resistant aGVHD. Patients with SR aGVHD had the worst clinical outcomes and poorest survival. Those with SS and SD aGVHD had similar clinical outcomes, both better than seen with SR aGVHD.
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Affiliation(s)
- Shannon Herzog
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Shanley
- Biostatistics Core, University of Minnesota Masonic Cancer Center, Minneapolis, Minnesota
| | - Shernan G Holtan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Najla El Jurdi
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
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2
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Wu YX, Wu DP, Ma X, Jiang SS, Hou MJ, Jing YT, Liu B, Li Q, Wang X, Wu YB, Hu XH. [Humanized anti-CD25 monoclonal antibody as a salvage therapy for steroid-refractory acute graft-versus-host disease after hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:755-761. [PMID: 38049320 PMCID: PMC10630582 DOI: 10.3760/cma.j.issn.0253-2727.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Indexed: 12/06/2023]
Abstract
Objective: To investigate the efficacy of humanized anti-CD25 monoclonal antibody for steroid-refractory acute graft-versus-host disease (SR-aGVHD) in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. Methods: A total of 64 patients with SR-aGVHD between June 2019 and October 2020 in Suchow Hopes Hematology Hospital were enrolled in this study. Humanized anti-CD25 monoclonal antibodies 1 mg·kg(-1)·d(-1) were administered on days 1, 3, and 8, and then once per week according to the disease progression. Efficacy was assessed at days 7, 14, and 28 after humanized anti-CD 25 treatment. Results: Of the 64 patients with a median age of 31 (15-63) years, 38 (59.4%) were male and 26 (40.6%) were female. The overall response (OR) rate of the humanized CD25 monoclonal antibody in 64 patients with SR-aGVHD on days 7, 14, and 28 were 48.4% (31/64), 53.1% (34/64), and 79.7% (51/64), respectively. Liver involvement is an independent risk factor for poor efficacy of humanized CD25 monoclonal antibody for SR-aGVHD at day 28 (OR=9.588, 95% CI 0.004-0.291, P=0.002). The median follow-up time for all patients was 17.1 (0.2-50.8) months from the start of humanized CD25 monoclonal antibody therapy. The 1- and 2-year OS rates were 63.2% (95% CI 57.1% -69.3%) and 52.6% (95% CI 46.1% -59.1%), respectively. The 1- and 2-year DFS rates were 58.4% (95% CI 52.1% -64.7%) and 49.8% (95% CI 43.4% -56.2%), respectively. The 1- and 2-year NRM rates were 28.8% (95% CI 23.1% -34.5%) and 32.9% (95% CI 26.8% -39.0%), respectively. The results of the multifactorial analysis showed that liver involvement (OR=0.308, 95% CI 0.108-0.876, P=0.027) and GVHD grade Ⅲ/Ⅳ (OR=9.438, 95% CI 1.211-73.577, P=0.032) were independent risk factors for OS. Conclusion: Humanized CD25 monoclonal antibody has good efficacy and safety for SR-aGVHD. This study shows that SR-aGVHD with pretreatment grade Ⅲ/Ⅳ GVHD and GVHD involving the liver has poor efficacy and prognosis and requires early intervention.
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Affiliation(s)
- Y X Wu
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - D P Wu
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematology Disease, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - X Ma
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematology Disease, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - S S Jiang
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - M J Hou
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - Y T Jing
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - B Liu
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - Q Li
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - X Wang
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - Y B Wu
- Soochow Hopes Hematology Hospital, Suzhou 215006, China
| | - X H Hu
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematology Disease, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou 215006, China
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3
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Jurdi NE, Hoover A, O'Leary D, Cao Q, Gupta A, Ebens C, Maakaron JE, Betts BC, Rashidi A, Juckett MB, Lund T, Bachanova V, MacMillan ML, Miller JS, Orchard PJ, Wagner JE, Vercellotti G, Weisdorf DJ, Dusenbery K, Terezakis S, Holtan SG. Phase II Study of Myeloablative 7-8/8-Matched Allotransplantation with Post-Transplantation Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil. Transplant Cell Ther 2023; 29:576.e1-576.e5. [PMID: 37311510 PMCID: PMC10530433 DOI: 10.1016/j.jtct.2023.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/15/2023]
Abstract
Graft-versus-host disease (GVHD) is the major toxicity of allogeneic hematopoietic cell transplantation (HCT). We hypothesized that a GVHD prophylaxis regimen of post-transplantation cyclophosphamide (PTCy), tacrolimus (Tac), and mycophenolate mofetil (MMF) would be associated with incidences of acute and chronic GVHD in patients receiving a matched or single antigen mismatched HCT. This Phase II study was conducted at the University of Minnesota using a myeloablative regimen of either total body irradiation (TBI) at a total dose of 1320 cGy, administered in 165-cGy fractions, twice daily from day -4 to day -1, or busulfan (Bu) 3.2 mg/kg daily (cumulative area under the curve, 19,000 to 21,000 μmol/min/L) plus fludarabine (Flu) 40 mg/m2 once daily on days -5 to -2, followed by a GVHD prophylaxis regimen of PTCy 50 mg/kg on days +3 and +4, Tac, and MMF beginning on day +5. The primary endpoint was the cumulative incidence of chronic GVHD necessitating systemic immunosuppression (IST) at 1 year post-transplantation. Between March 2018 and May 2022, we enrolled 125 pediatric and adult patients, with a median follow-up of 813 days. The incidence of chronic GVHD necessitating systemic IST at 1 year was 5.5%. The rate of grade II-IV acute GVHD was 17.1%, and that of grade III-IV acute GVHD was 5.5%. Two-year overall survival was 73.7%, and 2-year graft-versus-host disease-free, relapse-free survival was 52.2%. The 2-year cumulative incidence of nonrelapse mortality was 10.2%, and the rate of relapse was 39.1%. There was no statistically significant difference in survival outcomes between recipients of matched donor transplants versus recipients of 7/8 matched donor transplants. Our data show that myeloablative HCT with PTCy/Tac/MMF results in an extremely low incidence of severe acute and chronic GVHD in well-matched allogeneic HCT.
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Affiliation(s)
- Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Alex Hoover
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Daniel O'Leary
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ashish Gupta
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Christen Ebens
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Joseph E Maakaron
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Mark B Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Troy Lund
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Margaret L MacMillan
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Paul J Orchard
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - John E Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, Minnesota
| | - Gregory Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Stephanie Terezakis
- Department of Radiation Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
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4
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El Jurdi N, Hoover A, O'Leary D, Cao Q, Gupta A, Ebens C, Maakaron J, Betts BC, Rashidi A, Juckett M, Lund T, Bachanova V, MacMillan M, Miller J, Orchard P, Wagner J, Vercellotti G, Weisdorf D, Dusenbery K, Terezakis S, Holtan S. Phase II Study of Myeloablative 8/8- or 7/8-Matched Allotransplantation with Post-Transplant Cyclophosphamide, Tacrolimus, and Mycophenolate Mofetil: Marked Reduction in GVHD Risk Without Increased Relapse Risk Compared to Historical Cyclosporine/Methotrexate. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.24.23287521. [PMID: 37034603 PMCID: PMC10081397 DOI: 10.1101/2023.03.24.23287521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
Introduction Graft-versus host disease (GVHD) is a major limitation to the success of allogeneic hematopoietic cell transplant (HCT). We hypothesized that the GVHD prophylaxis regimen of post-transplant cyclophosphamide (PTCy), tacrolimus (Tac) and mycophenolate mofetil (MMF) would reduce the incidence of GVHD in patients receiving a matched or single antigen mismatched HCT without an increase in risk of malignant relapse. Methods This is a phase II study conducted at the University of Minnesota using a myeloablative regimen of either: (A) total body irradiation (TBI, total dose 1320 cGy, administered in 165 cGy fractions, twice a day from days -4 to -1) or (B) Busulfan 3.2mg/kg daily (cumulative AUC 19,000 - 21,000 μmol/min/L) plus fludarabine 160mg/m2 days -5 to -2, followed by a GVHD prophylaxis regimen of PTCy (50mg/kg days +3 and +4), Tac and MMF (beginning day +5). The primary endpoint is cumulative incidence of chronic GVHD requiring systemic immunosuppression at 1-year post-transplant. We compared results to our previous myeloablative protocol for matched donors utilizing cyclosporine/methotrexate (CSA/MTX) GVHD prophylaxis. Results From March 2018 - June 2022, we enrolled and treated 125 pediatric and adult patients with a median follow up of 472 days. Grade II-IV acute GVHD occurred in 16% (95% confidence interval (CI): 9-23%); Grade III-IV acute GVHD was 4% (CI: 0-8%). No patients experienced grade IV GVHD, and there were no deaths due to GVHD before day 100. Only 3 developed chronic GVHD requiring immune suppression, (4%, CI: 0-8%). Two-year overall survival (OS) was 80% (CI: 69-87%), and (graft-versus-host disease-free, relapse-free survival) GRFS 57% (CI: 45-67%), both higher than historical CSA/MTX. The incidence of grade II-IV aGVHD, cGVHD, and NRM were all lower with PTCy/Tac/MMF compared to historical CSA/MTX. One-quarter (25%) experienced relapse (CI: 15-36%) similar to historical CSA/MTX. There was no statistically significant difference in survival outcomes between recipients of matched versus 7/8 donors. Conclusion Myeloablative HCT with PTCy/Tac/MMF results in extremely low incidence of severe acute or chronic GVHD, the primary endpoint of this clinical trial. Relapse risk is not increased compared to our historical CSA/MTX cohort.
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Affiliation(s)
- Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Alex Hoover
- Division of Pediatric Hematology/Oncology, University of Minnesota, Minneapolis, MN, USA
| | - Daniel O'Leary
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Ashish Gupta
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Christen Ebens
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Joseph Maakaron
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Mark Juckett
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Troy Lund
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Margaret MacMillan
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Jeffrey Miller
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Paul Orchard
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - John Wagner
- Division of Pediatric Blood and Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN, USA
| | - Gregory Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
| | - Kathryn Dusenbery
- Department of Radiation Oncology, University of Minnesota, Minneapolis, MN
| | | | - Shernan Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN
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5
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Ritacco C, Köse MC, Courtois J, Canti L, Beguin C, Dubois S, Vandenhove B, Servais S, Caers J, Beguin Y, Ehx G, Baron F. Post-transplant cyclophosphamide prevents xenogeneic graft-versus-host disease while depleting proliferating regulatory T cells. iScience 2023; 26:106085. [PMID: 36843851 PMCID: PMC9947306 DOI: 10.1016/j.isci.2023.106085] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/12/2022] [Accepted: 01/25/2023] [Indexed: 02/02/2023] Open
Abstract
Graft-versus-host disease (GVHD) remains a serious limitation of allogeneic hematopoietic cell transplantation (allo-HCT). While post-transplant administration of cyclophosphamide (PTCy) is increasingly used as GVHD prophylaxis, its precise mechanisms of action and its impact on graft-versus-leukemia effects have remained debated. Here, we studied the mechanisms of xenogeneic GVHD (xGVHD) prevention by PTCy in different humanized mouse models. We observed that PTCy attenuated xGVHD. Using flow cytometry and single-cell RNA-sequencing, we demonstrated that PTCy depleted proliferative CD8+ and conventional CD4+ T cells but also proliferative regulatory T cells (Treg). Further, T-cell receptor β variable region sequencing (TCRVB) analyses demonstrated that highly xenoreactive T-cell clones were depleted by PTCy. Although Treg frequencies were significantly higher in PTCy-treated than in control mice on day 21, xGVHD attenuation by PTCy was not abrogated by Treg depletion. Finally, we observed that PTCy did not abrogate graft-versus-leukemia effects.
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Affiliation(s)
- Caroline Ritacco
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium
| | - Murat Cem Köse
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium
| | - Justine Courtois
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium
| | - Lorenzo Canti
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium
| | - Charline Beguin
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium
| | - Sophie Dubois
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium
| | - Benoît Vandenhove
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium
| | - Sophie Servais
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium,Department of Medicine, Division of Hematology, CHU of Liège, Liège 4000, Belgium
| | - Jo Caers
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium,Department of Medicine, Division of Hematology, CHU of Liège, Liège 4000, Belgium
| | - Yves Beguin
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium,Department of Medicine, Division of Hematology, CHU of Liège, Liège 4000, Belgium
| | - Grégory Ehx
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium,Corresponding author
| | - Frédéric Baron
- Hematology Research Unit, Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I³, University of Liège, Liège 4000, Belgium,Department of Medicine, Division of Hematology, CHU of Liège, Liège 4000, Belgium,Corresponding author
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6
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Nagler A, Labopin M, Arat M, Reményi P, Koc Y, Blaise D, Angelucci E, Vydra J, Kulagin A, Socié G, Rovira M, Sica S, Aljurf M, Gülbas Z, Kröger N, Brissot E, Peric Z, Giebel S, Ciceri F, Mohty M. Posttransplant cyclophosphamide‐based anti–graft‐vs‐host disease prophylaxis in patients with acute lymphoblastic leukemia treated in complete remission with allogeneic hematopoietic cell transplantation from human leukocyte antigen‐mismatched unrelated donors versus haploidentical donors: A study on behalf of the
ALWP
of the
EBMT. Cancer 2022; 128:3959-3968. [DOI: 10.1002/cncr.34452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Arnon Nagler
- Hematology Division Chaim Sheba Medical Center Tel‐Hashomer Israel
| | - Myriam Labopin
- Sorbonne Université INSERM UMR‐S 938, CRSA, Service d'hématologie et Thérapie Cellulaire, AP‐HP, Hôpital Saint‐Antoine Paris France
- European Society for Blood and Marrow Transplantation Paris Study Office/CEREST‐TC Paris France
| | - Mutlu Arat
- Istanbul Florence Nightingale Hospital HSCT Unit Istanbul Turkey
| | - Péter Reményi
- Dél‐pesti Centrumkórház‐Országos Hematológiaiés Infektológiai Intézet Department of Haematology and Stem Cell Transplant Budapest Hungary
| | - Yener Koc
- Medicana International Hospital Istanbul Bone MarrowTransplant Unit Istanbul Turkey
| | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes Marseille France
| | | | - Jan Vydra
- Institute of Hematology and Blood Transfusion Servicio de Hematología Prague Czech Republic
| | - Aleksandr Kulagin
- First State Pavlov Medical University of St. Petersburg Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology and Transplantation St. Petersburg Russia
| | - Gerard Socié
- Hopital St. Louis, Department of Hematology‐BMT Paris France
| | - Montserrat Rovira
- Hospital Clinic, Department of Hematology Institute of Hematology and Oncology Barcelona Spain
| | - Simona Sica
- Universita Cattolica S. Cuore, Istituto di Ematologia Ematologia Rome Italy
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Centre Oncology (Section of Adult Haematolgy/BMT) Riyadh Saudi Arabia
| | - Zafer Gülbas
- Anadolu Medical Center Hospital Bone Marrow Transplantation Department Kocaeli Turkey
| | - Nicolaus Kröger
- University Hospital Eppendorf Bone Marrow Transplantation Centre Hamburg Germany
| | - Eolia Brissot
- Sorbonne Université INSERM UMR‐S 938, CRSA, Service d'hématologie et Thérapie Cellulaire, AP‐HP, Hôpital Saint‐Antoine Paris France
- European Society for Blood and Marrow Transplantation Paris Study Office/CEREST‐TC Paris France
| | - Zinaida Peric
- University of Zagreb School of Medicine Zagreb Croatia
| | - Sebastian Giebel
- Maria Sklodowska‐Curie National Research Institute of Oncology Gliwice Poland
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplant, IRCCS San Raffaele Scientific Institute Milan Italy
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy Saint‐Antoine Hospital, AP‐HP, Sorbonne University Paris France
- Sorbonne University INSERM, Saint‐Antoine Research Centre Paris France
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7
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Ramanan R, Lim ABM, Tan JLC, Barmanray RD, Mason K, Collins J, Hillman M, Szer J, Bajel A, Ritchie D. Predictors and Outcomes of Dose Reduction of Methotrexate and Cyclosporin Graft-Versus-Host-Disease Prophylaxis Following Allogeneic Haematopoietic Cell Transplantation. Intern Med J 2022. [PMID: 35666197 DOI: 10.1111/imj.15829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 05/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Concern regarding dose-related toxicities of methotrexate (MTX) and cyclosporin (CYA) GVHD prophylaxis occasionally lead to dose alterations post allogeneic haematopoietic cell transplant (alloHCT). AIM To clarify causes of MTX and CYA dose alteration and assess impact on patient outcomes including GVHD, relapse, non-relapse mortality (NRM), and overall survival (OS). METHOD Analysis of retrospective data was performed in a single tertiary centre of patients who underwent alloHCT for any indication and who received GVHD prophylaxis with CYA and MTX between the years 2011 and 2015. Univariate analysis was conducted using the log-rank test for OS and using competing risk regression for NRM, relapse and GVHD. Fisher exact tests were used to determine if an association existed between each of the pre-transplant variables and MTX alteration. Multivariate models for OS and NRM were constructed using Cox proportional hazards modelling and competing risk regression respectively. RESULTS 54/196 (28%) had MTX alterations and 61/187 (33%) had CYA alterations. Reasons for MTX alteration included mucositis, renal or liver impairment, fluid overload and sepsis. Causes of CYA alteration were numerous but most commonly due to acute kidney impairment. MTX alteration was associated with inferior OS (HR 2.4, P=<0.001) and higher NRM (OR 4.6, P<0.001) at 6 years(y) post-landmark. CYA alteration was associated with greater NRM (OR 2.7, P= 0.0137) at 6y. GVHD rates were unaffected by dose alteration. CONCLUSIONS Our findings suggest dose alteration in MTX and CYA GVHD prophylaxis is associated with adverse survival outcomes in alloHCT, without a significant impact on GVHD rates. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Radha Ramanan
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Vic., Australia
| | - Andrew B M Lim
- Department of Clinical Haematology and Olivia Newton John Cancer Research Institute, Austin Health, Heidelberg, Vic., Australia
| | - Joanne L C Tan
- Department of Haematology, Alfred Health, Melbourne, Vic., Australia
| | - Rahul D Barmanray
- Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Vic., Australia
| | - Kate Mason
- Department of Clinical Haematology and Olivia Newton John Cancer Research Institute, Austin Health, Heidelberg, Vic., Australia
| | - Jenny Collins
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Vic., Australia
| | - Matthew Hillman
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Vic., Australia
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Vic., Australia
| | - Ashish Bajel
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Vic., Australia.,Sir Peter MacCallum Dept of Oncology, University of Melbourne, Parkville, Vic., Australia
| | - David Ritchie
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Vic., Australia
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8
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Biliński J, Jasiński M, Basak GW. The Role of Fecal Microbiota Transplantation in the Treatment of Acute Graft-versus-Host Disease. Biomedicines 2022; 10:biomedicines10040837. [PMID: 35453587 PMCID: PMC9027325 DOI: 10.3390/biomedicines10040837] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 12/11/2022] Open
Abstract
The number of allogeneic hematopoietic stem cell transplantations conducted worldwide is constantly rising. Together with that, the absolute number of complications after the procedure is increasing, with graft-versus-host disease (GvHD) being one of the most common. The standard treatment is steroid administration, but only 40–60% of patients will respond to the therapy and some others will be steroid-dependent. There is still no consensus regarding the best second-line option, but fecal microbiota transplantation (FMT) has shown encouraging preliminary and first clinically relevant results in recent years and seems to offer great hope for patients. The reason for treatment of steroid-resistant acute GvHD using this method derives from studies showing the significant immunomodulatory role played by the intestinal microbiota in the pathogenesis of GvHD. Depletion of commensal microbes is accountable for aggravation of the disease and is associated with decreased overall survival. In this review, we present the pathogenesis of GvHD, with special focus on the special role of the gut microbiota and its crosstalk with immune cells. Moreover, we show the results of studies and case reports to date regarding the use of FMT in the treatment of steroid-resistant acute GvHD.
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Affiliation(s)
- Jarosław Biliński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Human Biome Institute, 80-137 Gdansk, Poland
- Correspondence:
| | - Marcin Jasiński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Doctoral School, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Grzegorz W. Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Human Biome Institute, 80-137 Gdansk, Poland
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9
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Ehx G, Ritacco C, Hannon M, Dubois S, Delens L, Willems E, Servais S, Drion P, Beguin Y, Baron F. Comprehensive analysis of the immunomodulatory effects of rapamycin on human T cells in graft-versus-host disease prophylaxis. Am J Transplant 2021; 21:2662-2674. [PMID: 33512760 DOI: 10.1111/ajt.16505] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 12/24/2020] [Accepted: 01/18/2021] [Indexed: 01/25/2023]
Abstract
Graft-versus-host disease (GVHD) is a major cause of toxicity after allogeneic hematopoietic cell transplantation (allo-HCT). While rapamycin (RAPA) is commonly used in GVHD prophylaxis in combination with a calcineurin inhibitor (CNI), the understanding of its mechanism of action on human T cells is still incomplete. Here, we performed an extensive analysis of RAPA effects on human T cells in a humanized mouse model of GVHD, in ex-vivo T cell cultures and in patients given RAPA plus tacrolimus as GVHD prophylaxis after nonmyeloablative allo-HCT. We demonstrate that RAPA mitigates GVHD by decreasing T cell engraftment and differentiation, inhibiting CD8+ T cell activation and increasing the long-term IL-2 secretion, thereby supporting regulatory T cell (Treg) proliferation. In contrast, graft-versus-leukemia effects were not abrogated, as RAPA-treated T cells had increased resistance to apoptosis and retained their effector function and proliferative capacity upon re-stimulation. Importantly, we found that RAPA impact on Treg and CD8+ T cells was closely dependent upon IL-2 signaling and that therapeutic options interfering with IL-2, such as calcineurin inhibitors, antagonize the IL-2-dependent promotion of Treg mediated by RAPA. Our results suggest that RAPA immunological efficacy could be improved in combination with drugs having possible synergistic effects such as the hypomethylating agent 5-azacytidine.
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Affiliation(s)
- Grégory Ehx
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Caroline Ritacco
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Muriel Hannon
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Sophie Dubois
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Loic Delens
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium
| | - Evelyne Willems
- Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
| | - Sophie Servais
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
| | - Pierre Drion
- Experimental Surgery, GIGA-R & Credec, University of Liège, Liège, Belgium
| | - Yves Beguin
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
| | - Frédéric Baron
- Groupe Interdisciplinaire de Génoprotéomique Appliquée (GIGA)-I3, University of Liège, Liège, Belgium.,Department of Medicine, Division of Hematology, CHU and University of Liège, Liège, Belgium
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10
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Holtan SG, Versluis J, Weisdorf DJ, Cornelissen JJ. Optimizing Donor Choice and GVHD Prophylaxis in Allogeneic Hematopoietic Cell Transplantation. J Clin Oncol 2021; 39:373-385. [PMID: 33434075 DOI: 10.1200/jco.20.01771] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Shernan G Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jurjen Versluis
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Jan J Cornelissen
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
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11
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Mehta M, Gohil D, Khattry N, Kumar R, Sandur S, Sharma D, Checker R, Agarwal B, Jha D, Majumdar A, Gota V. Prevention of acute graft-versus-host-disease by Withaferin a via suppression of AKT/mTOR pathway. Int Immunopharmacol 2020; 84:106575. [PMID: 32416453 DOI: 10.1016/j.intimp.2020.106575] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/21/2020] [Accepted: 05/06/2020] [Indexed: 11/18/2022]
Abstract
Acute Graft versus Host Disease (aGVHD) is a frequent and serious complication in patients receiving allogeneic bone marrow transplantation (allo-BMT) and often requires rigorous prophylaxis. The current treatment regimens for aGVHD are associated with several side effects which necessitates the development of novel interventions that prevent aGVHD without precluding graft-versus-tumor effects. In the present study, we show that treatment of donor graft with plant steroidal lactone Withaferin A (WA) prior to transplantation markedly reduced aGVHD mediated damage in target organs without compromising the graft-versus.-tumor activity of the transplanted lymphocytes. WA abrogated post-transplant cytokine storm associated with allo-activation of donor lymphocytes. This was attributed to the ability of WA to inhibit early signaling events in T-cell activation including lymphoblast formation and activation of AKT/mTOR pathway. Mortality and morbidity related to allo-transplantation was significantly reduced in recipients of WA treated donor splenocytes compared to recipient of vehicle treated donor splenocytes. Further, WA treatment did not have any effect on reconstitution of lymphoid and myeloid lineages in recipients, resulting in stable and complete donor chimerism. In agreement with previous reports showing the effectiveness of WA in a mouse model of partial chimerism, our data further establishes that WA is able to attenuate aGVHD in an MHC-mismatched high dose chemo-conditioned murine model without compromising engraftment. This study provides compelling scientific basis for possible application of WA for prevention and treatment of aGVHD in patients receiving allo-BMT.
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Affiliation(s)
- Miten Mehta
- Department of Pharmacology and Toxicology, Bombay College of Pharmacy, Mumbai, India; Clinical Pharmacology laboratory, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, India
| | - Dievya Gohil
- Clinical Pharmacology laboratory, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, India
| | - Navin Khattry
- Department of Medical Oncology, Tata Memorial Centre, Mumbai, India
| | - Rajiv Kumar
- Department of Pathology, Tata Memorial Hospital, Mumbai, India
| | - Santosh Sandur
- Radiation Biology & Health Science Division, Bio-science Group, Bhabha Atomic Research Centre, Mumbai, India
| | - Deepak Sharma
- Radiation Biology & Health Science Division, Bio-science Group, Bhabha Atomic Research Centre, Mumbai, India
| | - Rahul Checker
- Radiation Biology & Health Science Division, Bio-science Group, Bhabha Atomic Research Centre, Mumbai, India
| | - Beamon Agarwal
- Department of Hematopathology, Montefiore Medical Centre, New York, NY, United States
| | - Dhruv Jha
- Birla Institute of Technology, Mesra Ranchi, Ranchi, India
| | - Anuradha Majumdar
- Department of Pharmacology and Toxicology, Bombay College of Pharmacy, Mumbai, India
| | - Vikram Gota
- Clinical Pharmacology laboratory, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Navi Mumbai, India.
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12
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Tripathi T, Yin W, Xue Y, Zurawski S, Fujita H, Hanabuchi S, Liu YJ, Oh S, Joo H. Central Roles of OX40L-OX40 Interaction in the Induction and Progression of Human T Cell-Driven Acute Graft-versus-Host Disease. Immunohorizons 2019; 3:110-120. [PMID: 31240276 DOI: 10.4049/immunohorizons.1900001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Graft-versus-host disease (GVHD) is one of the major obstacles for the success of allogeneic hematopoietic stem cell transplantation. Here, we report that the interaction between OX40L and OX40 is of critical importance for both induction and progression of acute GVHD (aGVHD) driven by human T cells. Anti-human OX40L monoclonal antibody (hOX40L) treatment could thus effectively reduce the disease severity in a xenogeneic-aGVHD (x-aGVHD) model in both preventative and therapeutic modes. Mechanistically, blocking OX40L-OX40 interaction with an anti-hOX40L antibody reduces infiltration of human T cells in target organs, including liver, gut, lung, and skin. It also decreases IL-21- and TNF-producing T cell responses, while promoting regulatory T cell (Treg) responses without compromising the cytolytic activity of CD8+ T cells. Single blockade of hOX40L was thus more effective than dual blockade of IL-21 and TNF in reducing the severity of aGVHD as well as mortality. Data from this study indicate that OX40L-OX40 interactions play a central role in the pathogenesis of aGVHD induced by human T cells. Therapeutic strategies that can efficiently interrupt OX40L-OX40 interaction in patients might have potential to provide patients with an improved clinical benefit.
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Affiliation(s)
- Trivendra Tripathi
- Department of Immunology, Mayo Clinic, Scottsdale, AZ 85259.,Baylor Institute for Immunology Research, Dallas, TX 75204; and
| | - Wenjie Yin
- Baylor Institute for Immunology Research, Dallas, TX 75204; and
| | - Yaming Xue
- Baylor Institute for Immunology Research, Dallas, TX 75204; and
| | - Sandra Zurawski
- Baylor Institute for Immunology Research, Dallas, TX 75204; and
| | - Haruyuki Fujita
- Baylor Institute for Immunology Research, Dallas, TX 75204; and
| | - Shino Hanabuchi
- Baylor Institute for Immunology Research, Dallas, TX 75204; and
| | - Yong-Jun Liu
- Baylor Institute for Immunology Research, Dallas, TX 75204; and.,Sanofi, Cambridge, MA 01701
| | - SangKon Oh
- Department of Immunology, Mayo Clinic, Scottsdale, AZ 85259.,Baylor Institute for Immunology Research, Dallas, TX 75204; and
| | - HyeMee Joo
- Department of Immunology, Mayo Clinic, Scottsdale, AZ 85259; .,Baylor Institute for Immunology Research, Dallas, TX 75204; and
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13
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Chhabra S, Liu Y, Hemmer MT, Costa L, Pidala JA, Couriel DR, Alousi AM, Majhail NS, Stuart RK, Kim D, Ringden O, Urbano-Ispizua A, Saad A, Savani BN, Cooper B, Marks DI, Socie G, Schouten HC, Schoemans H, Abdel-Azim H, Yared J, Cahn JY, Wagner J, Antin JH, Verdonck LF, Lehmann L, Aljurf MD, MacMillan ML, Litzow MR, Solh MM, Qayed M, Hematti P, Kamble RT, Vij R, Hayashi RJ, Gale RP, Martino R, Seo S, Hashmi SK, Nishihori T, Teshima T, Gergis U, Inamoto Y, Spellman SR, Arora M, Hamilton BK. Comparative Analysis of Calcineurin Inhibitor-Based Methotrexate and Mycophenolate Mofetil-Containing Regimens for Prevention of Graft-versus-Host Disease after Reduced-Intensity Conditioning Allogeneic Transplantation. Biol Blood Marrow Transplant 2018; 25:73-85. [PMID: 30153491 DOI: 10.1016/j.bbmt.2018.08.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/09/2018] [Indexed: 01/11/2023]
Abstract
The combination of a calcineurin inhibitor (CNI) such as tacrolimus (TAC) or cyclosporine (CYSP) with methotrexate (MTX) or with mycophenolate mofetil (MMF) has been commonly used for graft-versus-host disease (GVHD) prophylaxis after reduced-intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (alloHCT), but there are limited data comparing efficacy of the 2 regimens. We evaluated 1564 adult patients who underwent RIC alloHCT for acute myelogenous leukemia (AML) and acute lymphoblastic leukemia (ALL), chronic myelogenous leukemia (CML), and myelodysplastic syndrome (MDS) from 2000 to 2013 using HLA-identical sibling (matched related donor [MRD]) or unrelated donor (URD) peripheral blood graft and received CYSP or TAC with MTX or MMF for GVHD prophylaxis. Primary outcomes of the study were acute and chronic GVHD and overall survival (OS). The study divided the patient population into 4 cohorts based on regimen: MMF-TAC, MMF-CYSP, MTX-TAC, and MTX-CYSP. In the URD group, MMF-CYSP was associated with increased risk of grade II to IV acute GVHD (relative risk [RR], 1.78; P < .001) and grade III to IV acute GVHD (RR, 1.93; P = .006) compared with MTX-TAC. In the URD group, use of MMF-TAC (versus MTX-TAC) lead to higher nonrelapse mortality. (hazard ratio, 1.48; P = .008). In either group, no there was no difference in chronic GVHD, disease-free survival, and OS among the GVHD prophylaxis regimens. For RIC alloHCT using MRD, there are no differences in outcomes based on GVHD prophylaxis. However, with URD RIC alloHCT, MMF-CYSP was inferior to MTX-based regimens for acute GVHD prevention, but all the regimens were equivalent in terms of chronic GVHD and OS. Prospective studies, targeting URD recipients are needed to confirm these results.
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Affiliation(s)
- Saurabh Chhabra
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Ying Liu
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Institute for Health and Society, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Hemmer
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Luciano Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joseph A Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Daniel R Couriel
- Division of Hematology and Hematologic Malignancies, Utah Blood and Marrow Transplant Program, Salt Lake City, Utah
| | - Amin M Alousi
- Department of Stem Cell Transplantation, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Robert K Stuart
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Dennis Kim
- Department of Medical Oncology & Hematology, Princess Margaret Cancer Center, Toronto, Canada
| | - Olle Ringden
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Alvaro Urbano-Ispizua
- Department of Hematology, IDIBAPS, Institute of Research Josep Carreras, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ayman Saad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brenda Cooper
- Department of Medicine-Hematology and Oncology, University Hospitals Case Medical Center, Cleveland, Ohio
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Gerard Socie
- Department of Hematology, Hôpital Saint Louis, Paris, France
| | - Harry C Schouten
- Department of Hematology, Academische Ziekenhuis, Maastricht, the Netherlands
| | - Helene Schoemans
- Department of Hematology, 26-Department of Pediatrics, University Hospital of Leuven, Leuven, Belgium
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Jean Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Cancer Center, University of Maryland, Baltimore, Maryland
| | - Jean-Yves Cahn
- Department of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - John Wagner
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph H Antin
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Leo F Verdonck
- Departmentt of Hematology/Oncology, Isala Clinic, Zwolle, the Netherlands
| | - Leslie Lehmann
- Division of Hematologic Malignancies, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Margaret L MacMillan
- University of Minnesota Blood and Marrow Transplant Program, Minneapolis, Minnesota
| | - Mark R Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, Minnesota
| | - Melhem M Solh
- Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, Georgia
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Ravi Vij
- Division of Hematology and Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Robert P Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Rodrigo Martino
- Divison of Clinical Hematology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sachiko Seo
- Department of Hematology & Oncology, National Cancer Research Center East, Chiba, Japan
| | - Shahrukh K Hashmi
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia; Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, Minnesota
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Takanori Teshima
- Department of Hematology Kyushu University Hospital, Sapporo, Japan
| | - Usama Gergis
- Hematolgic Malignancies & Bone Marrow Transplant, Department of Medical Oncology, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, New York
| | - Yoshihiro Inamoto
- Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota.
| | - Betty K Hamilton
- Blood & Marrow Transplant Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
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14
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Abstract
PURPOSE OF REVIEW To provide a concise review of the oculoplastic manifestations of ocular graft versus host disease (GVHD), and to discuss their management. RECENT FINDINGS Ocular GVHD occurs as a common immune-mediated complication of hematopoietic stem cell transplantation that presents as a Stevens-Johnson-like syndrome in the acute phase or a Sjögren-like syndrome in the chronic phase. Cicatricial conjunctivitis may be underreported in ocular GVHD. The spectrum of oculoplastic manifestations includes GVHD of the skin, cicatricial entropion, nasolacrimal duct obstruction, and lacrimal gland dysfunction. Surgical treatment is indicated for patients with significant corneal complications from entropion. Surgical approach to repair of nasolacrimal duct obstruction is presented in this review, including modified approaches for treating patients at risk for keratitis sicca. Management of the ocular graft versus host patient may require a multidisciplinary approach involving collaboration from the oculoplastic surgeon, the corneal specialist, and the stem cell transplant physician. SUMMARY Oculoplastic manifestations of ocular GVHD typically present as cicatricial changes in the eyelid and lacrimal system. Careful oculoplastic and corneal evaluation are necessary when considering surgical management for the ocular GVHD patient.
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15
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Copacia JA, Taylor K, Laudick M, Rangarajan HG, Abu-Arja R, Auletta JJ, Pyle-Eilola A, Stanek J, Pai VB, Bajwa R. 70% Ethanol for Decontamination of Central Venous Lines Exposed to Calcineurin Inhibitors. Ann Pharmacother 2017; 52:32-39. [PMID: 28838253 DOI: 10.1177/1060028017709289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tacrolimus, commonly used for graft versus host disease prophylaxis is usually administered via a dedicated central venous line (CVL) and trough levels drawn from the unexposed lumen. Being an oil-based medication, it may be adsorbed to the inner lumen of the CVL and result in falsely high levels drawn from an inadvertently exposed lumen. There is no treatment for decontamination of such CVLs, and natural decay occurs over months before the CVL can be used to draw reliable trough levels. OBJECTIVE The primary objective of the study was to estimate the effectiveness of 70% ethanol locks for decontaminating CVLs exposed to tacrolimus. METHODS We studied the efficacy of 70% ethanol lock in decontaminating CVLs exposed to tacrolimus in patients during transplant. Trough tacrolimus levels were drawn from the exposed and unexposed (control) lumens at 8:00 am, followed by a 2-mL 70% ethanol lock instilled for a 2-hour dwell into the exposed (intervention) lumen. Trough tacrolimus levels were again drawn from both lumens at 8:00 pm and levels compared for efficacy. RESULTS All 20 sets showed a high 8 am trough level in the exposed intervention arm (median = 30 ng/mL), significantly greater ( P < 0.0001) than that in the control arm (median = 9.05 ng/mL), and were contaminated. After the 2-hour ethanol lock, 65% of the lumens were decontaminated. The difference between the control and intervention arms was no longer found to be statistically significant ( P = 0.0826). CONCLUSION A 2-hour 70% ethanol lock is effective for decontamination of CVLs exposed to tacrolimus.
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Affiliation(s)
- Jessica Ann Copacia
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kimberly Taylor
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Melissa Laudick
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Hemalatha G Rangarajan
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rolla Abu-Arja
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jeffery J Auletta
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Amy Pyle-Eilola
- 2 Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,3 Department of Clinical Pathology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Joseph Stanek
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Vinita B Pai
- 4 Department of Clinical Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rajinder Bajwa
- 1 Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
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16
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Tao T, Zhang YH, Xue SL, Wu DP, Chen F. Fulminant Laryngeal-tracheobronchial-pulmonary Aspergillosis: A Rare and Fatal Complication in Allogeneic Hematopoietic Stem Cell Transplantation Recipients. Intern Med 2017; 56:347-351. [PMID: 28154281 PMCID: PMC5348461 DOI: 10.2169/internalmedicine.56.7201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 23-year-old man who had previously undergone allogeneic hematopoietic stem cell transplantation (allo-HSCT) for severe aplastic anemia was diagnosed with invasive laryngeal-tracheobronchial-pulmonary aspergillosis after presenting with a persistent dry cough at six months post-transplantation based on the findings of laryngoscopy and fiberoptic bronchoscopy. A fiberoptic bronchoscope was used to remove the obstructive material from the patient's airway and posaconazole plus caspofungin were administered to successfully to treat the patient. Our report suggests that laryngoscopy and fiberoptic bronchoscopy should be considered as alternative approaches to the diagnosis and treatment of allo-HSCT recipients with persistent respiratory symptoms when invasive laryngeal aspergillosis and invasive tracheobronchial aspergillosis are suspected.
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Affiliation(s)
- Tao Tao
- Department of Hematology, the Xinghai Hospital of Suzhou Industrial Park, China
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17
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Pharmacokinetics, Pharmacodynamics and Pharmacogenomics of Immunosuppressants in Allogeneic Haematopoietic Cell Transplantation: Part I. Clin Pharmacokinet 2016; 55:525-50. [PMID: 26563168 DOI: 10.1007/s40262-015-0339-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although immunosuppressive treatments and target concentration intervention (TCI) have significantly contributed to the success of allogeneic haematopoietic cell transplantation (alloHCT), there is currently no consensus on the best immunosuppressive strategies. Compared with solid organ transplantation, alloHCT is unique because of the potential for bidirectional reactions (i.e. host-versus-graft and graft-versus-host). Postgraft immunosuppression typically includes a calcineurin inhibitor (cyclosporine or tacrolimus) and a short course of methotrexate after high-dose myeloablative conditioning, or a calcineurin inhibitor and mycophenolate mofetil after reduced-intensity conditioning. There are evolving roles for the antithymyocyte globulins (ATGs) and sirolimus as postgraft immunosuppression. A review of the pharmacokinetics and TCI of the main postgraft immunosuppressants is presented in this two-part review. All immunosuppressants are characterized by large intra- and interindividual pharmacokinetic variability and by narrow therapeutic indices. It is essential to understand immunosuppressants' pharmacokinetic properties and how to use them for individualized treatment incorporating TCI to improve outcomes. TCI, which is mandatory for the calcineurin inhibitors and sirolimus, has become an integral part of postgraft immunosuppression. TCI is usually based on trough concentration monitoring, but other approaches include measurement of the area under the concentration-time curve (AUC) over the dosing interval or limited sampling schedules with maximum a posteriori Bayesian personalization approaches. Interpretation of pharmacodynamic results is hindered by the prevalence of studies enrolling only a small number of patients, variability in the allogeneic graft source and variability in postgraft immunosuppression. Given the curative potential of alloHCT, the pharmacodynamics of these immunosuppressants deserves to be explored in depth. Development of sophisticated systems pharmacology models and improved TCI tools are needed to accurately evaluate patients' exposure to drugs in general and to immunosuppressants in particular. Sequential studies, first without and then with TCI, should be conducted to validate the clinical benefit of TCI in homogenous populations; randomized trials are not feasible, because there are higher-priority research questions in alloHCT. In Part I of this article, we review the alloHCT process to facilitate optimal design of pharmacokinetic and pharmacodynamics studies. We also review the pharmacokinetics and TCI of calcineurin inhibitors and methotrexate.
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18
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Servais S, Beguin Y, Delens L, Ehx G, Fransolet G, Hannon M, Willems E, Humblet-Baron S, Belle L, Baron F. Novel approaches for preventing acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Expert Opin Investig Drugs 2016; 25:957-72. [PMID: 27110922 DOI: 10.1080/13543784.2016.1182498] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Allogeneic hematopoietic stem cell transplantation (alloHSCT) offers potential curative treatment for a wide range of malignant and nonmalignant hematological disorders. However, its success may be limited by post-transplant acute graft-versus-host disease (aGVHD), a systemic syndrome in which donor's immune cells attack healthy tissues in the immunocompromised host. aGVHD is one of the main causes of morbidity and mortality after alloHSCT. Despite standard GVHD prophylaxis regimens, aGVHD still develops in approximately 40-60% of alloHSCT recipients. AREAS COVERED In this review, after a brief summary of current knowledge on the pathogenesis of aGVHD, the authors review the current combination of a calcineurin inhibitor with an antimetabolite with or without added anti-thymocyte globulin (ATG) and emerging strategies for GVHD prevention. EXPERT OPINION A new understanding of the involvement of cytokines, intracellular signaling pathways, epigenetics and immunoregulatory cells in GVHD pathogenesis will lead to new standards for aGVHD prophylaxis allowing better prevention of severe aGVHD without affecting graft-versus-tumor effects.
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Affiliation(s)
- Sophie Servais
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium.,b GIGA I3 , University of Liège , Liège , Belgium
| | - Yves Beguin
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium.,b GIGA I3 , University of Liège , Liège , Belgium
| | - Loic Delens
- b GIGA I3 , University of Liège , Liège , Belgium
| | - Grégory Ehx
- b GIGA I3 , University of Liège , Liège , Belgium
| | | | | | - Evelyne Willems
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium
| | - Stéphanie Humblet-Baron
- c Translational Immunology Laboratory , VIB , Leuven , Belgium.,d Department of Microbiology and Immunology , KUL-University of Leuven , Leuven , Belgium
| | | | - Frédéric Baron
- a Division of Hematology, Department of Medicine , University and CHU of Liège , Liège , Belgium.,b GIGA I3 , University of Liège , Liège , Belgium
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19
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A Pilot Study of Continuous Infusion of Mycophenolate Mofetil for Prophylaxis of Graft-versus-Host-Disease in Pediatric Patients. Biol Blood Marrow Transplant 2016; 22:682-689. [DOI: 10.1016/j.bbmt.2015.12.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 12/15/2015] [Indexed: 12/30/2022]
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20
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Rubio MT, Labopin M, Blaise D, Socié G, Contreras RR, Chevallier P, Sanz MA, Vigouroux S, Huynh A, Shimoni A, Bulabois CE, Caminos N, López-Corral L, Nagler A, Mohty M. The impact of graft-versus-host disease prophylaxis in reduced-intensity conditioning allogeneic stem cell transplant in acute myeloid leukemia: a study from the Acute Leukemia Working Party of the European Group for Blood and Marrow Transplantation. Haematologica 2015; 100:683-9. [PMID: 25769546 DOI: 10.3324/haematol.2014.119339] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 03/06/2015] [Indexed: 12/14/2022] Open
Abstract
The impact of the intensity of graft-versus-host-disease immunoprophylaxis on transplantation outcomes in patients undergoing transplantation following reduced-intensity conditioning is unclear. This study addresses this issue in 228 adult patients above 50 years of age with acute myeloid leukemia in first complete remission given peripheral blood stem cells from HLA-identical siblings after fludarabine and 2 days of intravenous busulfan reduced-intensity conditioning. A total of 152 patients received anti-thymocyte globulin, either in combination with cyclosporine A in 86 patients (group 1), or with cyclosporine A and mycophenolate mofetil or short course methotrexate in 66 patients (group 2). The remaining 76 patients did not receive anti-thymocyte globulin but were given cyclosporine A and methotrexate or mycophenolate mofetil (group 3). Incidences of grade II-IV acute graft-versus-host-disease were comparable in the three groups (16.5%, 29.5% and 19.5% in groups 1, 2 and 3, respectively, P=0.15). In multivariate analysis, the absence of anti-thymocyte globulin was the only factor associated with a higher risk of chronic graft-versus-host-disease (P=0.005), while the use of triple immunosuppression (group 3) was associated with an increased risk of relapse (P=0.003). In comparison to anti-thymocyte globulin and cyclosporine A alone, the other two strategies of graft-versus-host-disease prophylaxis were associated with reduced leukemia-free survival and overall survival (P=0.001 for each parameter), independently of the dose of anti-thymocyte globulin. These data suggest that fine tuning of the intensity of this prophylaxis can affect the outcome of transplantation and that anti-thymocyte globulin and cyclosporine A alone should be the preferred combination with the fludarabine-busulfan reduced-intensity conditioning regimen and sibling donors.
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Affiliation(s)
- Marie Thérèse Rubio
- Hôpital Saint Antoine, Service d'Hématologie et de Thérapie Cellulaire, Paris, France Université Pierre et Marie Curie, Paris, France INSERM UMRs938, CDR Saint Antoine, Paris, France
| | - Myriam Labopin
- Hôpital Saint Antoine, Service d'Hématologie et de Thérapie Cellulaire, Paris, France EBMT Data Office, Hôpital Saint Antoine, Paris, France
| | - Didier Blaise
- Programme de Transplantation & Therapie Cellulaire Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Gerard Socié
- Hôpital St. Louis, Dept. of Hematology - BMT, Paris, France
| | | | | | - Miguel A Sanz
- Hospital Universidad La Fe, Servicio de Hematologia y Oncologia, Valencia, Spain
| | | | - Anne Huynh
- Hôpital Purpan, CHU de Toulouse, Dept. Hematologie, France
| | - Avichai Shimoni
- Department of Bone Marrow Transplantation, Sheba Medical Center, Tel-Hashomer, Tel-Aviv University, Israel
| | | | | | - Lucía López-Corral
- Hospital Clinico, Servicio de Hematologia, Instituto Biosanitario de Salamanca (IBSAL), Spain
| | - Arnon Nagler
- Department of Bone Marrow Transplantation, Sheba Medical Center, Tel-Hashomer, Tel-Aviv University, Israel EBMT Data Office, Hôpital Saint Antoine, Paris, France
| | - Mohamad Mohty
- Hôpital Saint Antoine, Service d'Hématologie et de Thérapie Cellulaire, Paris, France Université Pierre et Marie Curie, Paris, France INSERM UMRs938, CDR Saint Antoine, Paris, France EBMT Data Office, Hôpital Saint Antoine, Paris, France
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Al-Homsi AS, Cole K, Bogema M, Duffner U, Williams S, Mageed A. Short Course of Post-Transplantation Cyclophosphamide and Bortezomib for Graft-versus-Host Disease Prevention after Allogeneic Peripheral Blood Stem Cell Transplantation Is Feasible and Yields Favorable Results: A Phase I Study. Biol Blood Marrow Transplant 2015; 21:1315-20. [PMID: 25765556 DOI: 10.1016/j.bbmt.2015.02.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
Abstract
An effective graft-versus-host disease (GVHD) preventative approach that preserves the graft-versus-tumor effect after allogeneic hematopoietic stem cell transplantation (HSCT) remains elusive. Standard GVHD prophylactic regimens suppress T cells indiscriminately and are suboptimal. Conversely, post-transplantation high-dose cyclophosphamide selectively destroys proliferating alloreactive T cells, allows the expansion of regulatory T cells, and induces long-lasting clonal deletion of intrathymic antihost T cells. It has been successfully used to prevent GVHD after allogeneic HSCT. Bortezomib has antitumor activity on a variety of hematological malignancies and exhibits a number of favorable immunomodulatory effects that include inhibition of dendritic cells. Therefore, an approach that combines post-transplantation cyclophosphamide and bortezomib seems attractive. Herein, we report the results of a phase I study examining the feasibility and safety of high-dose post-transplantation cyclophosphamide in combination with bortezomib in patients undergoing allogeneic peripheral blood HSCT from matched siblings or unrelated donors after reduced-intensity conditioning. Cyclophosphamide was given at a fixed dose (50 mg/kg on days +3 and +4). Bortezomib dose was started at .7 mg/m2, escalated up to 1.3 mg/m2, and was administered on days 0 and +3. Patients receiving grafts from unrelated donors also received rabbit antithymocyte globulin. The combination was well tolerated and allowed prompt engraftment in all patients. The incidences of acute GVHD grades II to IV and grades III and IV were 20% and 6.7%, respectively. With a median follow-up of 9.1 months (range, 4.3 to 26.7), treatment-related mortality was 13.5% with predicted 2-year disease-free survival and overall survival of 55.7% and 68%, respectively. The study suggests that the combination of post-transplantation cyclophosphamide and bortezomib is feasible and may offer an effective and practical GVHD prophylactic regimen. The combination, therefore, merits further examination.
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Affiliation(s)
- Ahmad-Samer Al-Homsi
- Blood and Marrow Transplantation Program, Spectrum Health, Grand Rapids, Michigan; Michigan State University, College of Human Medicine, Grand Rapids, Michigan.
| | - Kelli Cole
- Blood and Marrow Transplantation Program, Spectrum Health, Grand Rapids, Michigan
| | - Marlee Bogema
- Blood and Marrow Transplantation Program, Spectrum Health, Grand Rapids, Michigan
| | - Ulrich Duffner
- Blood and Marrow Transplantation Program, Spectrum Health, Grand Rapids, Michigan; Michigan State University, College of Human Medicine, Grand Rapids, Michigan
| | - Stephanie Williams
- Blood and Marrow Transplantation Program, Spectrum Health, Grand Rapids, Michigan; Michigan State University, College of Human Medicine, Grand Rapids, Michigan
| | - Aly Mageed
- Blood and Marrow Transplantation Program, Spectrum Health, Grand Rapids, Michigan; Michigan State University, College of Human Medicine, Grand Rapids, Michigan
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Hematopoietic stem-cell transplantation in the developing world: experience from a center in Western India. JOURNAL OF ONCOLOGY 2015; 2015:710543. [PMID: 25722722 PMCID: PMC4333194 DOI: 10.1155/2015/710543] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 12/18/2014] [Accepted: 12/22/2014] [Indexed: 11/23/2022]
Abstract
We describe our experience of first 50 consecutive hematopoietic stem-cell transplants (HSCT) done between 2007 and 2012 at the Apollo Hospital, Gandhinagar, 35 autologous HSCT and 15 allogeneic HSCT. Indications for autologous transplant were multiple myeloma, non-Hodgkin lymphoma, Hodgkin lymphoma, and acute myeloid leukemia, and indications for allogeneic transplants were thalassemia major, aplastic anaemia, chronic myeloid leukemia, and acute lymphoblastic and myeloid leukaemia. The median age of autologous and allogeneic patient's cohort was 50 years and 21 years, respectively. Median follow-up period for all patients was 39 months. Major early complications were infections, mucositis, acute graft versus host disease, and venoocclusive disease. All of our allogeneic and autologous transplant patients survived during the first month of transplant. Transplant related mortality (TRM) was 20% (N = 3) in our allogeneic and 3% (N = 1) in autologous patients. Causes of these deaths were disease relapse, sepsis, hemorrhagic complications, and GVHD. 46% of our autologous and 47% of our allogeneic patients are in complete remission phase after a median follow-up of 39 months. 34% of our autologous patients and 13% of our allogeneic patients had disease relapse. Overall survival rate in our autologous and allogeneic patients is 65.7% and 57.1%, respectively. Our results are comparable to many national and international published reports.
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Methotrexate for the Treatment of Graft-versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation. J Transplant 2014; 2014:980301. [PMID: 25405023 PMCID: PMC4227326 DOI: 10.1155/2014/980301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/22/2014] [Accepted: 09/23/2014] [Indexed: 12/12/2022] Open
Abstract
Glucocorticoids have been the primary treatment of graft-versus-host disease (GVHD) over the past decade. Complete responses to steroid therapy are usually expected in almost one-third of aGVHD cases and partial response is anticipated in another one-third of patients. However, for those patients not responding to corticosteroid treatment, there is no standard second-line therapy for acute or chronic GVHD. Methotrexate (MTX) for treatment of steroid refractory GVHD has been evaluated in a number of studies. Results from peer-reviewed original articles were identified and the pooled data analyzed. Despite several limitations in data collection and analysis, weekly administration of methotrexate at a median dose of 7.5 mg/m2 seems to be safe with minimal toxicities in the context of both aGVHD and cGVHD treatments. The observed overall response (OR) in patients with aGVHD to MTX treatment in the published studies was 69.9%, with complete response (CR) in 59.2% and PR in 10.6%. In cGVHD the OR was 77.6%, with CR reported in 49.6% and PR in 28% of patients. Predictors of better responses were lower grade GVHD, cutaneous involvement, and isolated organ involvement. MTX as a steroid sparing agent might reduce long-term complications and improve the quality of life of GVHD affected individuals.
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Lai YR, Chen YH, Hu DM, Jiang M, Liu QF, Liu L, Hou J, Schwarzenberger P, Li QC, Zhang ZM, Liu KY, Huang XJ. Multicenter phase II study of a combination of cyclosporine a, methotrexate and mycophenolate mofetil for GVHD prophylaxis: results of the Chinese Bone Marrow Transplant Cooperative Group (CBMTCG). J Hematol Oncol 2014; 7:59. [PMID: 25139202 PMCID: PMC4237802 DOI: 10.1186/s13045-014-0059-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 07/31/2014] [Indexed: 01/18/2023] Open
Abstract
Background Improvement of current GVHD prophylactic therapies remains an important goal in the allo-HSCT. We have described a novel prophylaxis regimen in a single institution trial. The Chinese Bone Marrow Transplant Cooperative Group (CBMTCG) initiated a phase II multicenter study. Methods The study was designed as a prospective, single arm phase II open-label, multicenter clinical trial. The primary endpoint was improvement of aGVHD by 25% over historical control (40%) in Chinese patients. 508 patients were enrolled. All of the patients received cyclosporine A (CsA), methotrexate (MTX) and mycophenolate mofetil (MMF) (0.5-1.0 g daily for 30 days) as GVHD prophylaxis regimen. Results The primary endpoint was met with cumulative incidences of grades 2 to 4 and grades 3 to 4 aGVHD of 23.2% and 10.3%, respectively. Incidence for cGVHD was 67.4%. The non-relapse mortality (NRM) rate was 18.4% at 2 years. The probabilities of leukemia free survival (LFS) for non-advanced stage and advanced stage patients at 2 years were 69.7% and 44.8% respectively (p = 0.000). Recipient age ≥ 40 years, advanced stage and Busulfan-Fludarabine(BuFlu) conditioning regimen were identified as major risk factors for aGVHD. Recipient age ≥ 40 years, BuFlu conditioning regimens, female donor/male recipient and prior aGVHD were associated with cGVHD. Despite lower RM (relapse mortality), patients with grade 2–4 aGVHD had higher NRM and worse OS and LFS compared to patients with grade 0–1 aGVHD. In contrast, patients with cGVHD had better OS and LFS and lower RM compared to patients without cGVHD. Conclusion The novel GVHD regimen decreased the risk for aGVHD by 42% without improving the risk for cGVHD compared to historical controls. Development of aGVHD was associated with worse OS and LFS as well as higher NRM. In contrast, cGVHD was associated with improved OS and LFS likely attributed to a GVL effect.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Xiao-Jun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.
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25
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Belaiche S, Yafour N, Balcaen S, Beguin Y, Borel C, Bruno B, Godin S, Labussiere-Wallet H, Sanhamut N, Charbonnier A, de Berranger E, Konopacki-Potet J, Turlure P, Yakoub-Agha I. Immunosuppresseurs dans la prévention de la réaction du greffon contre l’hôte : rapport de la SFGM-TC. ACTA ACUST UNITED AC 2014; 62:197-203. [DOI: 10.1016/j.patbio.2014.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 05/14/2014] [Indexed: 01/08/2023]
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Peluso I, Palmery M. Is a flavonoid-rich diet with steamer cooking safe during calcineurin inhibitors therapy? J Clin Pharm Ther 2014; 39:471-4. [PMID: 24938126 DOI: 10.1111/jcpt.12186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 05/19/2014] [Indexed: 12/14/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Dietary therapy is recommended for decreasing the symptoms of the metabolic syndrome and the risk of type 2 diabetes and cardiovascular diseases in subjects on calcineurin inhibitors. However, food-drug interactions may occur particularly with patients on such immunosuppressive therapy. This article comments on the benefit/risk assessment of a flavonoid-rich diet and steam-cooking of such food during calcineurin inhibitors therapy. COMMENT Patients are commonly advised against consuming citrus fruits and juices, grape juice and green tea. High vegetable intake may however increase the risk of food-diet interactions by inhibiting drug metabolic enzymes and transporters. Vegetable glucosinolates are potential interactants and may lead to adverse effects of drugs with narrow therapeutic indices and in the presence of genetic polymorphism. Examples of food components with potential drug interactants include all members of the Brassicaceae family. WHAT IS NEW AND CONCLUSION The potential additive and synergistic effects of flavonoids with other molecules in interfering with drug bioavailability need to be taken into account. The risk is highest with drugs with a narrow therapeutic index and in subjects with genetic polymorphisms of proteins involved in the disposition of those drugs.
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Affiliation(s)
- I Peluso
- Department of Physiology and Pharmacology "V. Erspamer", "Sapienza" University of Rome, Rome, Italy
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Abstract
Over the past 5 years, many novel approaches to early diagnosis, prevention, and treatment of acute graft-versus-host disease (aGVHD) have been translated from the bench to the bedside. In this review, we highlight recent discoveries in the context of current aGVHD care. The most significant innovations that have already reached the clinic are prophylaxis strategies based upon a refinement of our understanding of key sensors, effectors, suppressors of the immune alloreactive response, and the resultant tissue damage from the aGVHD inflammatory cascade. In the near future, aGVHD prevention and treatment will likely involve multiple modalities, including small molecules regulating immunologic checkpoints, enhancement of suppressor cytokines and cellular subsets, modulation of the microbiota, graft manipulation, and other donor-based prophylaxis strategies. Despite long-term efforts, major challenges in treatment of established aGVHD still remain. Resolution of inflammation and facilitation of rapid immune reconstitution in those with only a limited response to corticosteroids is a research arena that remains rife with opportunity and urgent clinical need.
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Sung AD, Chao NJ. Acute graft-versus-host disease: are we close to bringing the bench to the bedside? Best Pract Res Clin Haematol 2013; 26:285-92. [PMID: 24309532 DOI: 10.1016/j.beha.2013.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplant (AHSCT) associated with significant morbidity and mortality. This review focuses on the pathophysiology, prevention, and treatment of acute GVHD. Specifically, we explain how new discoveries in immunology have expanded our understanding of GVHD, in which tissue damage from chemotherapy or radiation results in cytokine release, activating T cells, resulting in proliferation and differentiation, trafficking to target organs, and tissue destruction and inflammation. Insights into the mechanisms of this disease relate directly to the development of preventive strategies and therapies, such as immunosuppression, calcineurin inhibitors, T-cell depletion, CCR5 antagonists, gut decontamination, extracorporeal photopheresis, and more. Understanding the immunobiology of GVHD and developing effective preventions and treatments are critical to the continuing success of AHSCT.
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Affiliation(s)
- Anthony D Sung
- Duke University Medical Center, Division of Hematologic Malignancies and Cellular Therapy, 2400 Pratt St, Suite 9100, Box 3961, Durham, NC 27710, USA.
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Hou CY, Xu LL, Chen H, Liu N, Jiang M, Wang GQ, Zhang L, Wang XH, Zeng YJ. Intestinal aGVHD and infection after hematopoietic stem cell transplantation. Med Sci Monit 2013; 19:802-6. [PMID: 24077343 PMCID: PMC3792879 DOI: 10.12659/msm.889408] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background We aimed to guide clinical nursing by studying the relationship between intestinal acute graft-versus-host disease and intestinal infection after hematopoietic stem cell transplantation. Material/Methods We present an effective nursing method by comparing and analyzing the degree, duration time, and volume of diarrhea, and the distribution of pathogens in 44 patients who developed intestinal aGVHD after hematopoietic stem cell transplantation (24 patients with no intestinal infection). Results 21.4% of patients with grade I–II intestinal aGVHD developed into intestinal infection and 87.5% of patients with grade III–IV intestinal aGVHD developed into intestinal infection (P<0.05). Higher mortality was found in the grade III–IV intestinal aGVHD patients with intestinal infection. Patient age had no effect on the incidence of GVHD according to our data (P<0.05). We found remarkable differences in the amount and duration of diarrhea between patients with and without intestinal infection (P<0.05). The most common pathogens cultivated were Candida glabrata (24%) and Candida albicans (22.67%). Conclusions The incidence of intestinal infection increased remarkably after intestinal aGVHD occurred. Severe aGVHD can easily lead to fungus infection. Nursing care can decrease the incidence of intestinal infection in aGVHD.
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Zhu X, Lai X, Luo Y, Shi J, Tan Y, Zheng W, He J, Xie W, Li L, Zhang J, Ye X, Lin M, Cai Z, Huang H. Combination of low-dose mycophenolate mofetil with cyclosporine and methotrexate as GVHD prophylaxis in unrelated donor allogeneic stem cell transplantation. Leuk Res 2013; 37:1046-51. [PMID: 23849987 DOI: 10.1016/j.leukres.2013.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 06/11/2013] [Accepted: 06/12/2013] [Indexed: 11/29/2022]
Abstract
We report the results of HLA-matched unrelated donor allogeneic stem cell transplantation with new GVHD prophylaxis regimen consisted of cyclosporine, methotrexate and low-dose mycophenolate mofetil in 139 patients with hematologic malignancies. The incidence of grades II-IV and III-IV acute GVHD were 43.0% and 17.3%, respectively. The incidence of chronic GVHD was 42.1%, with 16.5% extensive grade. The cumulative incidence of transplant-related mortality at 100 days and 3 years were 7.9% and 29.7%, respectively. Three-year overall survival, disease-free survival and relapse incidence were 58.7%, 55.3% and 19.6%, respectively. These results suggest the new regime may be effective for the prophylaxis of acute and chronic GVHD in unrelated donor transplantation.
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Affiliation(s)
- Xiaoli Zhu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
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Qian L, Wu Z, Shen J. Advances in the treatment of acute graft-versus-host disease. J Cell Mol Med 2013; 17:966-75. [PMID: 23802653 PMCID: PMC3780546 DOI: 10.1111/jcmm.12093] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 05/15/2013] [Indexed: 12/13/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has been widely used for the treatment of hematologic malignant and non-malignant hematologic diseases and other diseases. However, acute graft-versus-host disease (GVHD) is a life-threatening complication of allogeneic transplantation. Acute GVHD may occur in 30% of transplant recipients, which is a syndrome of erythematous skin eruption, cholestatic liver disease and intestinal dysfunction, resulting from the activation of donor T lymphocytes by host antigen-presenting cells, resulting in an immune-mediated inflammatory response. Recent scientific advances in the understanding of the pathogenesis involved in the development of acute GVHD and clinical investigation have provided more effective therapeutic strategies for acute GVHD. This review focuses on major scientific and clinical advances in the treatment of acute GVHD.
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Affiliation(s)
- Liren Qian
- Department of Haematology, Navy General Hospital, Beijing, China.
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Ram R, Storb R. Pharmacologic prophylaxis regimens for acute graft-versus-host disease: past, present and future. Leuk Lymphoma 2013; 54:1591-601. [PMID: 23278640 DOI: 10.3109/10428194.2012.762978] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract Acute graft-versus-host disease (GVHD) has compromised and continues to compromise the benefits associated with allogeneic hematopoietic cell transplant to cure malignant and non-malignant diseases. Pharmacologic interventions to prevent GVHD have emerged as a major objective of research in the immunology and transplant fields. A better understanding of the pathobiology behind the GVHD process has led the way to novel approaches and medications. Here we review the present arsenal of medications used to prevent GVHD, focusing on past experience and the current evidence, and discuss future potential targets.
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Affiliation(s)
- Ron Ram
- Bone Marrow Transplantation Unit, Rabin Medical Center, Beilinson Hospital and the Sackler School of Medicine, Tel Aviv University, Israel.
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Ehinger KHJ, Hansson MJ, Sjövall F, Elmér E. Bioequivalence and tolerability assessment of a novel intravenous ciclosporin lipid emulsion compared to branded ciclosporin in Cremophor ® EL. Clin Drug Investig 2013; 33:25-34. [PMID: 23179472 PMCID: PMC3586182 DOI: 10.1007/s40261-012-0029-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ciclosporin is used as an immunosuppressant in current clinical practice but recent research implies novel indications for the drug, such as neuro- and cardioprotection. The intravenous formulation currently on the market, Sandimmune(®) Injection (Sandimmune(®)), uses Cremophor(®) EL as emulsifying excipient. Cremophor(®) EL is known to cause hypersensitivity reactions in some patients, ranging from skin reactions to potentially fatal anaphylactic shock. OBJECTIVES The primary objective was to assess if CicloMulsion(®), a Cremophor(®) EL-free lipid emulsion of ciclosporin for intravenous administration, is bioequivalent to Sandimmune(®), and the secondary objective was to compare the tolerability profiles of the two preparations. METHODS This was a single-centre, open-label, subject-blind, laboratory-blind, single-dose, randomized, two-treatment, two-period, two-sequence crossover study of the pharmacokinetics of two formulations of intravenous ciclosporin. Fifty-two healthy volunteer subjects were administered 5 mg/kg of each of the two formulations of ciclosporin as a 4-h intravenous infusion. The last blood sample was acquired 48 h after the end of the infusion. Bioequivalence assessments according to current guidelines were performed. RESULTS The geometric mean ratios for CicloMulsion(®)/Sandimmune(®) (90 % confidence interval [CI]) were 0.90 (0.88, 0.92) for AUC(0-last) (area under the blood concentration-time curve from time zero to time of last measurable concentration) and 0.95 (0.92, 0.97) for C(max) (maximum blood concentration). For all additional variables analysed, the 90 % CIs were also within the accepted bioequivalence range of 0.80-1.25. One anaphylactoid and one anaphylactic reaction, both classified as serious adverse events, were reported after treatment with Sandimmune(®). No serious adverse events were recorded after treatment with CicloMulsion(®). CONCLUSION We have assessed the pharmacokinetics and tolerability of a new Cremophor(®) EL-free lipid emulsion of ciclosporin, CicloMulsion(®), compared to Sandimmune(®). The proportion of adverse events was significantly higher for the Cremophor(®) EL-based product Sandimmune(®). We conclude that CicloMulsion(®) is bioequivalent to Sandimmune(®) and exhibits fewer adverse reactions.
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Rowley SD, Friedman T, Korngold R. Hematopoietic stem cell transplantation for malignant diseases. Clin Immunol 2013. [DOI: 10.1016/b978-0-7234-3691-1.00097-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sung AD, Chao NJ. Concise review: acute graft-versus-host disease: immunobiology, prevention, and treatment. Stem Cells Transl Med 2012; 2:25-32. [PMID: 23283494 DOI: 10.5966/sctm.2012-0115] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplant (AHSCT) associated with significant morbidity and mortality. This review focuses on the pathophysiology, clinical features, prevention, and treatment of acute GVHD. Specifically, we explain how new discoveries in immunology have expanded our understanding of GVHD, in which tissue damage from chemotherapy or radiation results in cytokine release, which activates T cells, resulting in proliferation and differentiation, trafficking to target organs, and tissue destruction and inflammation. Insights into the mechanisms of this disease relate directly to the development of preventive strategies and therapies, such as immunosuppression, T-cell depletion, calcineurin inhibitors, CCR5 antagonists, gut decontamination, extracorporeal photopheresis, and more. We also discuss how GVHD affects the gut, liver, and skin, as well as diagnosis, grading, and scoring. We end by examining future directions of treatment, including new immunomodulators and biomarkers. Understanding the immunobiology of GVHD and developing effective preventions and treatments are critical to the continuing success of AHSCT.
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Abstract
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HCT) is an effective immunotherapy for human cancer. More than 20 000 allo-HCTs are performed each year worldwide, primarily for the treatment of hematologic malignancies. Several technical innovations implemented in allo-HCT over past 2 decades have reduced NRM by 50% and improved overall survival. The allo-HCT practice has changed with the introduction of peripheral blood, cord blood, and haploidentical transplantations and reduced-intensity conditioning, and the patient population is also different regarding age and diagnosis. However, both acute and chronic GVHD remain serious barriers to successful allo-HCT and it is not clear that a major improvement has occurred in our ability to prevent or treat GVHD. Nevertheless, there is an increasing knowledge of the biology and clinical manifestations and the field is getting better organized. These advances will almost certainly lead to major progress in the near future. As the long list of new potential targets and respective drugs are developed, systems need to be developed for rapid testing of them in clinical practice. The current reality is that no single agent has yet to be approved by the US Food and Drug Administration for GVHD prevention or therapy. Although a primary goal of these efforts is to develop better therapies for GVHD, the ultimate goal is to develop treatments that lead to effective prevention or preemption of life-threatening and disabling GVHD manifestations while harnessing the desirable graft-versus-tumor effects.
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Perez-Simón JA, Martino R, Parody R, Cabrero M, Lopez-Corral L, Valcarcel D, Martinez C, Solano C, Vazquez L, Márquez-Malaver FJ, Sierra J, Caballero D. The combination of sirolimus plus tacrolimus improves outcome after reduced-intensity conditioning, unrelated donor hematopoietic stem cell transplantation compared with cyclosporine plus mycofenolate. Haematologica 2012; 98:526-32. [PMID: 23065527 DOI: 10.3324/haematol.2012.065599] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Different types of graft-versus-host disease prophylaxis have been proposed in the setting of reduced intensity and non-myeloablative allogeneic stem cell transplantation. An alternative combination with sirolimus and tacrolimus has recently been tested although comparative studies against the classical combination of a calcineurin inhibitor and mycophenolate mofetil or methotrexate are lacking. We describe the results of a prospective, multicenter trial using sirolimus + tacrolimus as immunoprophylaxis, and compare this approach with our previous experience using cyclosporine + mycophenolate in the setting of unrelated donor transplantation setting after reduced-intensity conditioning. Forty-five patients received cyclosporine + mycophenolate between 2002 and mid-2007, while the subsequent 50 patients, who were transplanted from late 2007, were given sirolimus + tacrolimus. No significant differences were observed in terms of hematopoietic recovery or acute graft-versus-host disease overall, although gastrointestinal acute graft-versus-host disease grade ≥ 2 was more common in the cyclosporine + mycophenolate group (55% versus 21%, respectively, P=0.003). The 1-year cumulative incidence of chronic graft-versus-host disease was 50% versus 90% for the patients treated with the sirolimus- versus cyclosporine-based regimen, respectively (P<0.001), while the incidence of extensive chronic disease was 27% versus 49%, respectively (P=0.043). The 2-year non-relapse mortality rate was 18% versus 38% for patients receiving the sirolimus- versus the cyclosporine-based regimen, respectively (P=0.02). The event-free survival and overall survival at 2 years were 53% versus 29% (P=0.028) and 70% versus 45% (P=0.018) among patients receiving the sirolimus- versus the cyclosporine-based regimen, respectively. In conclusion, in the setting of reduced intensity transplantation from an unrelated donor, promising results can be achieved with the combination of sirolimus + tacrolimus, due to a lower risk of chronic graft-versus-host disease and non-relapse mortality, which translates into better event-free and overall survival rates, in comparison with those achieved with cyclosporine + mycophenolate.
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Affiliation(s)
- Jose Antonio Perez-Simón
- Servicio de Hematología, Hospital Universitario/Instituto de Biomedicina (IBIS)/CSIC, Seville, Spain.
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Affiliation(s)
- Sergio Giralt
- Memorial Sloan-Kettering Cancer Center, New York, NY
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Kim IW, Yun HY, Choi B, Han N, Park SY, Lee ES, Oh JM. ABCB1 C3435T genetic polymorphism on population pharmacokinetics of methotrexate after hematopoietic stem cell transplantation in Korean patients: a prospective analysis. Clin Ther 2012; 34:1816-26. [PMID: 22796246 DOI: 10.1016/j.clinthera.2012.06.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/11/2012] [Accepted: 06/20/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Methotrexate (MTX) is often used to prevent graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT). However, MTX has great pharmacokinetic variability and its use can result in fatal complications and/or infections after HSCT. OBJECTIVES The purposes of this study were to build a population pharmacokinetic model of MTX treatment in Korean patients who have undergone HSCT and to identify covariates, including genetic polymorphisms, that affect the pharmacokinetic properties of MTX. METHODS Clinical characteristics and MTX concentration data for 20 post-HSCT patients were collected. For each patient, ABCB1, ABCC2, ATIC, GGH, MTHFR, and TYMS genotyping was performed. Population pharmacokinetic analysis was performed using the NONMEM program. Analysis of MTX pharmacokinetic properties was accomplished using a 2-compartment pharmacokinetic model that incorporated first-order conditional estimation methods with interaction. The effects of a variety of demographic and genetic factors on MTX disposition were investigated. RESULTS The study population consisted of 12 men (60%) and 8 women (40%). Median age and body weight were 28 years (range, 18-49 years) and 55.6 kg (range, 44.8-80.8 kg), respectively. Within the study population, the estimated mean MTX clearance (CL) was 7.08 L/h, whereas the mean central compartment volume (V(1)) of MTX distribution was 19.4 L. MTX CL was significantly affected by glomerular filtration rate (GFR), penicillin use, and the ABCB1 3435 genotype. Interindividual variabilities for CL and V(1) were 21.6% and 73.3%. A 10-mL/min GFR increase was associated with a 32% increase in mean MTX CL, whereas penicillin use was associated with a decrease in MTX CL of 61%. MTX CL was significantly greater (by ∼21%) in patients with the ABCB1 3435 CC and CT genotype than in those with the ABCB1 3435 TT genotype (P < 0.001). CONCLUSIONS There was great interindividual variation in MTX pharmacokinetic properties in patients who had undergone HSCT. GFR, concurrent penicillin use, and the presence of the ABCB1 3435 C<T genotypes significantly affected MTX CL. The MTX population pharmacokinetic model developed here may provide useful information for individualizing MTX therapy after HSCT.
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Affiliation(s)
- In-Wha Kim
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Gwanak-gu, Seoul, Korea
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Baron F, Storb R. Mesenchymal stromal cells: a new tool against graft-versus-host disease? Biol Blood Marrow Transplant 2012; 18:822-40. [PMID: 21963621 PMCID: PMC3310956 DOI: 10.1016/j.bbmt.2011.09.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Accepted: 09/10/2011] [Indexed: 12/18/2022]
Abstract
Mesenchymal stromal cells (MSCs) represent a heterogeneous subset of multipotent cells that can be isolated from several tissues including bone marrow and fat. MSCs exhibit immunomodulatory and anti-inflammatory properties that prompted their clinical use as prevention and/or treatment for severe graft-versus-host disease (GVHD). Although a number of phase I-II studies have suggested that MSC infusion was safe and might be effective for preventing or treating acute GVHD, definitive proof of their efficacy remains lacking thus far. Multicenter randomized studies are ongoing to more precisely assess the impact of MSC infusion on GVHD prevention/treatment, whereas further research is performed in vitro and in animal models with the aims of determining the best way to expand MSCs ex vivo as well as the most efficient dose and schedule of MSCs administration. After introducing GVHD, MSC biology, and results of MSC infusion in animal models of allogeneic hematopoietic cell transplantation, this article reviews the results of the first clinical trials investigating the use of MSC infusion as prevention or treatment of GVHD.
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Affiliation(s)
- Frédéric Baron
- Department of Medicine, Division of Hematology, University and CHU of Liège, CHU Sart-Tilman, Liège, Belgium.
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Hudspeth MP, Heath TS, Chiuzan C, Garrett-Mayer E, Nista E, Burton L, Ragucci D. Folinic acid administration after MTX GVHD prophylaxis in pediatric allo-SCT. Bone Marrow Transplant 2012; 48:46-9. [DOI: 10.1038/bmt.2012.82] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Aslanian H, Chander B, Robert M, Cooper D, Proctor D, Seropian S, Jain D. Prospective evaluation of acute graft-versus-host disease. Dig Dis Sci 2012; 57:720-5. [PMID: 22011927 DOI: 10.1007/s10620-011-1938-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 09/30/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Graft-versus-host disease (GVHD) is a common complication of allogeneic bone marrow transplantation. Severe GVHD carries significant morbidity and mortality and remains one of the leading causes of treatment failure. Unfortunately, intestinal GVHD may present with a variety of non-specific symptoms and diagnosis based on clinical presentation is often inaccurate; biopsy is therefore needed for definitive diagnosis. At present, the optimal endoscopic approach to the diagnosis of gastrointestinal GVHD remains uncertain. AIMS The primary aims of our study were: (1) to evaluate the yield of upper versus lower endoscopy, and (2) to determine which anatomic regions were most likely to provide a histologic diagnosis. METHODS We conducted a prospective study of 27 consecutive patients who had undergone stem cell transplantation within the past 100 days and were referred to the Yale Gastrointestinal Procedure center between August 2002 and February 2006 for the evaluation of suspected acute GVHD. All patients underwent standardized endoscopic evaluation of the upper and lower gastrointestinal tract with biopsies. The diagnostic yield of upper versus lower endoscopy was compared in all patients. RESULTS GVHD was identified in 18 of the 27 patients (67%). Of those with GVHD, 15 patients (83%) had diffuse intestinal involvement. Six of 10 patients (60%) with an endoscopically normal EGD had GVHD on biopsies of the upper gastrointestinal tract. Six of 13 (46%) patients with an endoscopically normal appearing colonoscopy had GVHD on colonic biopsies. Two of 18 (11%) patients had isolated GVHD of the upper intestinal tract and 1 (6%) had isolated colonic GVHD. Rectal biopsy alone identified 89% (16 of 18) of GVHD cases and all 16 cases of GVHD with colonic involvement. A diagnosis of GVHD was not altered by the additional performance of biopsy of the proximal colon or terminal ileum. CONCLUSIONS In the present study, the majority of cases of acute GVHD demonstrate diffuse upper and lower gastrointestinal involvement with rectal, sigmoid, gastric and duodenal biopsies having similarly diagnostic yield. Based on our findings, we recommend starting with flexible sigmoidoscopy with rectal biopsy alone in patients who are poor candidates to undergo full colonoscopy with sedation or in those in whom GVHD is strongly suspected based on clinical findings. However, more extensive evaluations may be necessary to rule out infection and should be considered in those with no contraindications to sedation and in whom other differential diagnoses are also being considered.
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Affiliation(s)
- Harry Aslanian
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, 333 Cedar Street, LMP 1080, New Haven, CT 06510, USA
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Medd P, Monk I, Danby R, Malladi R, Clifford R, Ellis A, Roberts D, Hatton C, Vyas P, Littlewood T, Peniket A. Methotrexate dose delivery is more important than ciclosporin level in graft-versus-host disease prophylaxis following T-replete reduced-intensity sibling allogeneic stem cell transplant. Int J Hematol 2011; 94:266-278. [DOI: 10.1007/s12185-011-0920-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 08/11/2011] [Accepted: 08/12/2011] [Indexed: 11/28/2022]
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Chavan R, El-Azhary R. Cutaneous graft-versus-host disease: rationales and treatment options. Dermatol Ther 2011; 24:219-28. [DOI: 10.1111/j.1529-8019.2011.01397.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
PURPOSE OF REVIEW Administration of high-dose cyclophosphamide after transplantation inhibits both graft rejection and graft-versus-host disease (GvHD) in mouse models of allogeneic blood or marrow transplantation (alloBMT). This strategy has recently been adapted to human transplantation. RECENT FINDINGS The safety and efficacy of high-dose posttransplantation cyclophosphamide, when given in combination with tacrolimus and mycophenolate mofetil, was first demonstrated after nonmyeloablative conditioning and allografting using human leukocyte antigen (HLA)-mismatched related donors. Further analysis shows that increasing HLA disparity does not worsen overall outcome. High-dose posttransplantation cyclophosphamide was also found to be effective as sole prophylaxis of acute and chronic GvHD after HLA-matched alloBMT. SUMMARY Taking advantage of the differential susceptibility of proliferating, alloreactive T cells over nonproliferating, nonalloreactive T cells to high-dose cyclophosphamide, and owing to the drug's stem cell sparing effects, this novel strategy provides a unique opportunity to optimize GvHD prophylaxis after HLA-matched alloBMT and increase the use of HLA-mismatched related donors. Well tolerated and effective mismatched related alloBMT provides access to essentially everyone, such as patients with sickle cell anemia, in need of the procedure.
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