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Hasan M, Choi J, Akter H, Kang H, Ahn M, Lee S. Antibody-Conjugated Magnetic Nanoparticle Therapy for Inhibiting T-Cell Mediated Inflammation. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2307148. [PMID: 38161230 PMCID: PMC10953552 DOI: 10.1002/advs.202307148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/01/2023] [Indexed: 01/03/2024]
Abstract
Tolerance induction is critical for mitigating T cell-mediated inflammation. Treatments based on anti-CD3 monoclonal antibody (mAb) play a pivotal role in inducing such tolerance. Anti-CD3 mAb conjugated with dextran-coated magnetic nanoparticles (MNPs) may induce inflammatory tolerance is posited. MNPs conjugated with anti-CD3 mAb (Ab-MNPs) are characterized using transmission and scanning electron microscopy, and their distribution is assessed using a nanoparticle tracking analyzer. Compared to MNPs, 90% of Ab-MNPs increased in size from 54.7 ± 0.5 to 71.7 ± 2.7 nm. The in vitro and in vivo studies confirmed the therapeutic material as nontoxic and biocompatible. Mice are administered various dosages of Ab-MNPs before receiving concanavalin-A (ConA), an inflammation inducer. Preadministration of Ab-MNPs, as opposed to MNPs or anti-CD3 mAb alone, significantly reduced the serum levels of interferon-γ and interleukin-6 in ConA-treated mice. Additionally, the transdermal stamp patch as an effective delivery system for Ab-MNPs is validated. This study demonstrates the utility of the Ab-MNP complex in pathologies associated with T cell-mediated hyperinflammation, such as organ transplantation and COVID-19.
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Affiliation(s)
- Mahbub Hasan
- Department of Digital HealthcareSangji UniversityWonju26339South Korea
- Department of Biochemistry and Molecular BiologyLife Science FacultyBangabandhu Sheikh Mujibur Rahman Science and Technology UniversityGopalganj8100Bangladesh
| | - Jong‐Gu Choi
- Department of Digital HealthcareSangji UniversityWonju26339South Korea
| | - Hafeza Akter
- Department of Digital HealthcareSangji UniversityWonju26339South Korea
| | - Hasung Kang
- Department of MedicineCollege of MedicineSeoul National UniversitySeoul08826South Korea
| | - Meejung Ahn
- Department of Animal ScienceCollege of Life ScienceSangji UniversityWonju26339South Korea
| | - Sang‐Suk Lee
- Department of Digital HealthcareSangji UniversityWonju26339South Korea
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Gao Y, Li W, Bu X, Xu Y, Cai S, Zhong J, Du M, Sun H, Huang L, He Y, Hu X, Liu Q, Jin H, Wang Q, Ping B. Human Amniotic Mesenchymal Stem Cells Inhibit aGVHD by Regulating Balance of Treg and T Effector Cells. J Inflamm Res 2021; 14:3985-3999. [PMID: 34429630 PMCID: PMC8378934 DOI: 10.2147/jir.s323054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/27/2021] [Indexed: 12/14/2022] Open
Abstract
Background Acute graft versus host disease (aGVHD) remains a leading cause of transplant-related mortality following allogeneic haematopoietic cell transplantation (allo-HCT). Human amniotic mesenchymal stem cells (hAMSCs) are a novel mesenchymal stem cells (MSCs), which have stronger proliferation and immunomodulatory ability compared with bone marrow mesenchymal stem cells (BM-MSCs). Besides, as the amniotic membrane is often treated as medical waste after delivery, hAMSCs can be obtained conveniently and noninvasively. The aim of this study was to explore the therapeutic efficacy and underlying mechanisms of hAMSCs transplantation for the humanized aGVHD mouse model. Methods We established a humanized aGVHD mouse model by transplanting human peripheral blood mononuclear cells (PBMCs) into NOD-PrkdcscidIL2rγnull (NPG) mice, human amniotic membrane collected from discarded placenta of healthy pregnant women after delivery and hAMSCs were extracted from amniotic membrane and expanded in vitro. Mice were divided into untreated group (Control), aGVHD group (aGVHD), and hAMSCs treatment group (aGVHD+hAMSCs), the hAMSCs labeled with GFP were administered to aGVHD mice to explore the homing ability of hAMSCs. T effector and regulatory T cells (Tregs) levels and cytokines of each group in target organs were detected by flow cytometry and cytometric bead array (CBA), respectively. Results We successfully established a humanized aGVHD mouse model using NPG mice. The hAMSCs have the ability to inhibit aGVHD in this mouse model through reduced villous blunting and lymphocyte infiltration of the gut while reducing inflammatory edema, tissue destruction and lymphocyte infiltration into the parenchyma of the liver and lung. hAMSCs suppressed CD3+CD4+ T and CD3+CD8+ T cell expression and increased the proportion of Tregs, and besides, hAMSCs can reduce the levels of IL-17A, INF-γ, and TNF in aGVHD target organs. Conclusion The NPG murine environment was capable of activating human T cells to produce aGVHD pathology to mimic aGVHD as in humans. The hAMSCs controlled aGVHD by decreasing inflammatory cytokine secretion within target organs by modulating the balance of Tregs and T effector cells in humanized mice.
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Affiliation(s)
- Ya Gao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Weiru Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Xiaoyin Bu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Ying Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Shengchun Cai
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Jinman Zhong
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Meixue Du
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Haitao Sun
- Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, People's Republic of China
| | - Liping Huang
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Yongjian He
- Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Xiumei Hu
- Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Hua Jin
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Qian Wang
- Department of Laboratory Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510280, People's Republic of China.,Department of Laboratory Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Baohong Ping
- Department of Hematology, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
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Phase II trial of natalizumab with corticosteroids as initial treatment of gastrointestinal acute graft-versus-host disease. Bone Marrow Transplant 2020; 56:1006-1012. [PMID: 32895491 DOI: 10.1038/s41409-020-01049-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022]
Abstract
The α4ß7 integrin is upregulated on naive and memory T cell subsets in patients who subsequently develop gastrointestinal (GI) acute GVHD. Natalizumab (Tysabri®, Biogen Inc.) acts against the α4 subunit that mediates homing of lymphocytes to the GI tract. We initiated a phase II study of natalizumab with corticosteroids for initial treatment of acute GI GVHD. In total, 300 mg IV of natalizumab was given, with steroids initiated up to 3 days prior. Twenty-one subjects were treated, median age was 63 years (range 38-74), and 15 (71%) were male. Eighteen (86%) underwent RIC, 15 (71%) received MUD, and all received PBSCs. Overall GVHD at enrollment was grade II in 4 and grade III in 17. The primary endpoint, day 56 GVHD-free survival rate, was attained in 33.3%. The overall response rate at day 28 and 56 was 57% and 52%, respectively. Six of eight CRs were durable for 1 year. Five experienced toxicity possibly related to natalizumab and ten had infections before day 100. 2-year OS was 43% (95% CI 22-62%) and 2-year NRM was 52% (95% CI 29-71%). Natalizumab with corticosteroids as initial treatment of acute GI GVHD is safe, effective, and durable.
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Luan J, Zhao Y, Zhang Y, Miao J, Li J, Chen ZN, Zhu P. CD147 blockade as a potential and novel treatment of graft rejection. Mol Med Rep 2017; 16:4593-4602. [PMID: 28849101 PMCID: PMC5647014 DOI: 10.3892/mmr.2017.7201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 08/01/2017] [Indexed: 11/25/2022] Open
Abstract
Cluster of differentiation (CD)147 is highly involved in the T cell activation process. High CD147 expression is observed on the surfaces of activated T cells, particularly CD4+ T cells. In organ transplantation, it is important to prevent graft rejection resulting from the excessive activation of T cells, particularly CD4+ T cells, which exhibit a key role in amplifying the immune response. The present study aimed to investigate the effects of CD147 blockade in vitro and in vivo and used a transplant rejection system to assess the feasibility of utilizing CD147 antibody-based immunosuppressant drugs for the treatment of graft rejection. The effects of CD147 antibodies were evaluated on lymphocyte proliferation stimulated by phytohemagglutinin or CD3/CD28 magnetic beads and in a one-way mixed lymphocyte reaction (MLR) system in vitro. For the in vivo analysis, an allogeneic skin transplantation mouse model was used. CD147 antibodies were effective against lymphocytes, particularly CD4+T lymphocytes, and were additionally effective in the one-way MLR system. In the allogeneic skin transplantation mouse model, the survival of transplanted skin was extended in the CD147 antibody-treated group. Furthermore, the level of inflammatory cell infiltration in transplanted skin was reduced. CD147 blockade decreased the serum levels of interleukin (IL)-17 and the proportions of peripheral blood CD4+ and CD8+ memory T cells. The data demonstrated that CD147 blockade suppressed skin graft rejection, primarily by suppressing CD4+T and memory T cell proliferation, indicating that CD147 exhibits great potential as a target of immunosuppressant drugs.
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Affiliation(s)
- Jing Luan
- National Translational Science Center for Molecular Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yu Zhao
- National Translational Science Center for Molecular Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Yang Zhang
- National Translational Science Center for Molecular Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Jinlin Miao
- National Translational Science Center for Molecular Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Jia Li
- National Translational Science Center for Molecular Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Zhi-Nan Chen
- National Translational Science Center for Molecular Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
| | - Ping Zhu
- National Translational Science Center for Molecular Medicine, The Fourth Military Medical University, Xi'an, Shaanxi 710032, P.R. China
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A phase 3 randomized trial comparing inolimomab vs usual care in steroid-resistant acute GVHD. Blood 2016; 129:643-649. [PMID: 27899357 DOI: 10.1182/blood-2016-09-738625] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/11/2016] [Indexed: 12/15/2022] Open
Abstract
Treatment of steroid-resistant acute graft-versus-host disease (GVHD) remains an unmet clinical need. Inolimomab, a monoclonal antibody to CD25, has shown encouraging results in phase 2 trials. This phase 3 randomized, open-label, multicenter trial compared inolimomab vs usual care in adult patients with steroid-refractory acute GVHD. Patients were randomly selected to receive treatment with inolimomab or usual care (the control group was treated with antithymocyte globulin [ATG]). The primary objective was to evaluate overall survival at 1 year without changing baseline allocated therapy. A total of 100 patients were randomly placed: 49 patients in the inolimomab arm and 51 patients in the ATG arm. The primary criteria were reached by 14 patients (28.5%) in the inolimomab and 11 patients (21.5%) in the ATG arms, with a hazard ratio of 0.874 (P = .28). With a minimum follow-up of 1 year, 26 (53%) and 31 (60%) patients died in the inolimomab and ATG arms, respectively. Adverse events were similar in the 2 arms, with fewer viral infections in the inolimomab arm compared with the ATG arm. The primary end point of this randomized phase 3 trial was not achieved. The lack of a statistically significant effect confirms the need for development of more effective treatments for acute GVHD. This trial is registered to https://www.clinicaltrialsregister.eu/ctr-search/search as EUDRACT 2007-005009-24.
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Hu R, Liu Y, Song Y, Su M, Lu X, Rood D, Lai L. Recombinant IL-7/HGFβ hybrid cytokine separates acute graft-versus-host-disease from graft-versus-tumour activity by altering donor T cell trafficking. Br J Haematol 2016; 175:505-516. [PMID: 27447780 DOI: 10.1111/bjh.14268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 06/07/2016] [Indexed: 11/29/2022]
Abstract
Given that donor T cells from a transplant contribute both the desired graft-versus-tumour (GVT) effect and detrimental graft-versus-host disease (GVHD), strategies to separate GVHD and GVT activity are a major clinical goal. We have previously demonstrated that in vivo administration of a recombinant (r)IL-7/HGFβ hybrid cytokine, consisting of interleukin-7 (IL-7, IL7) and the β-chain of hepatocyte growth factor (HGFβ), significantly inhibits the growth of cancer cells in murine tumour models. The antit-umour effect of rIL-7/HGFβ is related to a marked infiltration T cells in the tumour tissues. We have also shown that GVHD was not induced in rIL-7/HGFβ-treated T cell-depleted allogeneic haematopoietic stem cell transplantation (HSCT) recipients. We show here that, in T cell-replete allogeneic HSCT murine models, rIL-7/HGFβ attenuated acute GVHD (aGVHD), while promoting GVT activity. This was related to an alteration of donor T cell trafficking, with an increased infiltration of donor T cells into tumour tissues and the lympho-haematopoietic system but decreased number of the T cells in the GVHD target organs. Therefore, rIL-7/HGFβ may offer a new tool to alleviate aGVHD while prompting GVT, and to study the molecular regulation of T cell trafficking.
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Affiliation(s)
- Rong Hu
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA.,Guizhou Medical University, Guizhou, China
| | - Yalan Liu
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Yinhong Song
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Min Su
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Xiuling Lu
- Department of Pharmaceutical Sciences, University of Connecticut, Storrs, CT, USA
| | - Debra Rood
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Laijun Lai
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA. .,University of Connecticut Stem Cell Institute, University of Connecticut, Storrs, CT, USA.
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Pescovitz MD. Daclizumab: humanized monoclonal antibody to the interleukin-2 receptor. Expert Rev Clin Immunol 2014; 1:337-44. [DOI: 10.1586/1744666x.1.3.337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Andres AM, Santamaría ML, Ramos E, Sarriá J, Molina M, Hernandez F, Encinas JL, Larrauri J, Prieto G, Tovar JA. Graft-vs-host disease after small bowel transplantation in children. J Pediatr Surg 2010; 45:330-6; discussion 336. [PMID: 20152346 DOI: 10.1016/j.jpedsurg.2009.10.071] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 10/27/2009] [Indexed: 12/26/2022]
Abstract
PURPOSE Graft-vs-host disease (GVHD) is a rare complication of transplantation of organs rich in immunocompetent cells. The goal of this study was to report the features of GVHD after small bowel transplantation (SBTx) in children. METHODS The study involved a retrospective review of patients undergoing SBTx between 1999 and 2009 who had GVHD. RESULTS Of 46 children receiving 52 intestinal grafts (2 liver-intestine and 3 multivisceral), 5 (10%) developed GVHD. Median age at transplant was 42 (19-204) months. Baseline immunosupression consisted of tacrolimus and steroids supplemented with thymoglobulin (n = 2) or basiliximab (n = 3) for induction. Median time between transplantation and GVHD was 47 (16-333) days. All patients had generalized rash, 2 had diarrhea, and 2 had respiratory symptoms. Other symptoms were glomerulonephritis (n = 1) and conjunctivitis (n = 1). Four developed severe hematologic disorders. The diagnosis was confirmed by skin biopsy in 4 patients and supported by chimerism studies in two. Colonoscopy and opthalmoscopic findings were also suggestive in one. Treatment consisted of steroids and decrease of tacrolimus, with partial response in four. Other immunosuppressants were used in refractory or recurrent cases. Three patients died within 4 months after diagnosis. CONCLUSION Graft-vs-host disease is a devastating complication of SBTx, with high mortality probably associated with severe immunologic dysregulation.
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Affiliation(s)
- Ane M Andres
- Department of Pediatric Surgery, Hospital Universitario La Paz, Paseo de Castellana 261, 28046 Madrid, Spain.
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Schechter T, Afzal S, Finkelstein Y, Koren G, Doyle J, Dupuis LL. Daclizumab therapy for children with corticosteroid-resistant acute graft-vs.-host disease. Pediatr Transplant 2009; 13:332-7. [PMID: 18482218 DOI: 10.1111/j.1399-3046.2008.00959.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
MAbs such as daclizumab have shown promising results in the treatment of corticosteroid-resistant aGVHD. Data describing the efficacy of MAbs in children are limited. We describe the efficacy of daclizumab in children with corticosteroid-resistant aGVHD. Seventeen children (0.4-16.2 yr) received daclizumab for aGVHD. Safety was evaluated in all 17. Response was evaluated in the 15 children who received a full course of daclizumab. A PR was defined as improvement of aGVHD symptoms in at least one organ without worsening in other organs. We observed an overall response rate (CR plus PR) of 40% (6/15). Four children had a CR and two had a PR. aGVHD involving the gut had the highest response rate (five of 10; 50%). Adverse effects attributed to daclizumab were limited to an episode of reactive arthritis. Mortality was high (47%; eight of 17) though five of the six responders to daclizumab survived. The mean length of follow-up in the surviving nine patients was 32 months (range seven to 48). We conclude that daclizumab is effective in the treatment of children with corticosteroid-resistant aGVHD, especially in patients with gut involvement.
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Affiliation(s)
- Tal Schechter
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
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Hamadani M, Hofmeister CC, Jansak B, Phillips G, Elder P, Blum W, Penza S, Lin TS, Klisovic R, Marcucci G, Farag SS, Devine SM. Addition of infliximab to standard acute graft-versus-host disease prophylaxis following allogeneic peripheral blood cell transplantation. Biol Blood Marrow Transplant 2008; 14:783-9. [PMID: 18541197 DOI: 10.1016/j.bbmt.2008.04.006] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Accepted: 04/14/2008] [Indexed: 10/22/2022]
Abstract
Infliximab, a chimeric monoclonal antibody (mAb) against tumor necrosis factor (TNF)-alpha, has shown activity against steroid refractory acute graft-versus-host disease (aGVHD). We conducted a prospective trial of infliximab for the prophylaxis of aGVHD. Patients older than 20 years undergoing myeloablative allogeneic stem cell transplantation (SCT) for hematologic malignancies were eligible. GVHD prophylaxis consisted of infliximab given 1 day prior to conditioning and then on days 0, +7, +14, +28, and +42, together with standard cyclosporine (CSA) and methotrexate (MTX). Nineteen patients with a median age of 53 years were enrolled. All patients received peripheral blood allografts from matched sibling (n = 14) or unrelated donors (n = 5). Results were compared with a matched historic control group (n = 30) treated contemporaneously at our institution. The cumulative incidences of grades II-IV aGVHD in the infliximab and control groups were 36.8% and 36.6%, respectively (P = .77). Rates of chronic GVHD were 78% and 61%, respectively (P = .22). Significantly more bacterial and invasive fungal infections were observed in the infliximab group (P = .01 and P = .02, respectively). Kaplan-Meier estimates of 2-year overall survival (OS) and progression free survival (PFS) for patients receiving infliximab were 42% and 36%, respectively. The corresponding numbers for patients in the control group were 46% and 43%, respectively. The addition of infliximab to standard GVHD prophylaxis did not lower the risk of GVHD and was associated with an increased risk of bacterial and invasive fungal infections.
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Affiliation(s)
- Mehdi Hamadani
- Division of Hematology & Oncology, Arthur G. James Cancer Hospital, The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA
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Refractory Graft Versus Host Disease After Pediatric Intestinal Transplantation—Beware of Pre-Existing Immunodeficiency. Transplantation 2008; 86:179. [DOI: 10.1097/tp.0b013e31817b912e] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tsiodras S, Samonis G, Boumpas DT, Kontoyiannis DP. Fungal infections complicating tumor necrosis factor alpha blockade therapy. Mayo Clin Proc 2008. [PMID: 18241628 DOI: 10.1016/s0025-6196(11)60839-2] [Citation(s) in RCA: 185] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tumor necrosis factor a (TNF-alpha) blockade has emerged as a useful therapy for collagen vascular diseases or graft-vs-host disease. Fungal infections complicating such therapy have been reported sporadically. MEDLINE and PubMed databases (from January 1, 1966, to June 1, 2007) were searched for reports of invasive fungal infections (IFIs) associated with the 3 available anti-TNF- alpha agents, ie, infliximab, etanercept, and adalimumab. Of the 281 cases of IFI associated with TNF-alpha inhibition, 226 (80%) were associated with infliximab, 44 (16%) with etanercept, and 11 (4%) with adalimumab. Fungal infections associated with infliximab occurred a median of 55 days (interquartile range [IQR], 15-140 days) after initiation of therapy and 3 infusions of the medication (IQR, 2-5), whereas those associated with etanercept occurred a median of 144 days (IQR, 46-240 days) after initiation of therapy. The median age of patients was 58 years (IQR, 44-68 years), and 62% were male. Use of at least 1 other immunosuppressant medication, typically a systemic corticosteroid, was reported during the course of the fungal infection in 102 (98%) of the 104 patients for whom data were available. The most prevalent IFIs were histoplasmosis (n=84 [30%]), candidiasis (n=64 [23%]), and aspergillosis (n equals 64 [23%]). Pneumonia was the most common pattern of infection. Of the 90 (32%) of 281 cases for which outcome information was available, 29 fatalities (32%) were recorded. Tumor necrosis factor a blockade is associated with IFI across a range of host groups. A high index of suspicion in patients treated with TNF-alpha antagonists is recommended because the course of such infections can be serious or fulminant, and rapid access to health care should be provided. Surveillance of IFIs complicating TNF-alpha blockade and other biologic therapies is warranted through well-organized prospective patient registries.
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Affiliation(s)
- Sotirios Tsiodras
- 4th Academic Department of Internal Medicine and Infectious Diseases, Attikon University General Hospital, University of Athens Medical School, Greece
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Gómez-Almaguer D, Ruiz-Argüelles GJ, del Carmen Tarín-Arzaga L, González-Llano O, Gutiérrez-Aguirre H, Cantú-Rodríguez O, Jaime-Pérez J, Carrasco-Yalán A, Giralt S. Alemtuzumab for the treatment of steroid-refractory acute graft-versus-host disease. Biol Blood Marrow Transplant 2008; 14:10-5. [PMID: 18158956 DOI: 10.1016/j.bbmt.2007.08.052] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Accepted: 10/16/2007] [Indexed: 11/27/2022]
Abstract
The treatment of steroid-refractory acute graft-versus-host disease (aGVHD) remains a clinical challenge, for which no standard therapy exists. Alemtuzumab is a humanized anti-CD52 monoclonal antibody (mAb) that has been successfully used as part of conditioning regimens for hematopoietic stem cell transplantation (HSCT) to prevent GVHD. The purpose of this study was to evaluate the safety and efficacy of alemtuzumab in treating steroid-refractory aGVHD (>or=grade II) following HSCT. Eighteen patients received subcutaneous alemtuzumab 10 mg daily on 5 consecutive days. Response was assessed at day 28 following initiation of alemtuzumab. Eight patients had grade II aGVHD, 8 had grade III, and 2 had grade IV. The main organ involved was the liver in 4 patients, gastrointestinal (GI) tract in 5, skin in 3, skin and liver in 3, and skin and GI tract in 3. Fifteen patients (83%) responded to alemtuzumab, including 6 (33%) with complete response. All 3 unresponsive patients died of GVHD. Ten of 15 responders are alive at median follow-up of 11 months (range: 3-24). Infections occurred in 14 patients, including cytomegalovirus (CMV) reactivation in 11. Grade 3 neutropenia and thrombocytopenia occurred in 6 and 4 patients, respectively. Alemtuzumab was well tolerated, and induces promising response rates in steroid-refractory aGVHD.
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Affiliation(s)
- David Gómez-Almaguer
- Servicio de Hematología, Hospital Universitario Dr. José E. González, Universidad Autónoma Nuevo León, Monterrey, NL, México.
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Ke Y, Sun D, Zhang P, Jiang G, Kaplan HJ, Shao H. Suppression of established experimental autoimmune uveitis by anti-LFA-1alpha Ab. Invest Ophthalmol Vis Sci 2007; 48:2667-75. [PMID: 17525198 PMCID: PMC2587054 DOI: 10.1167/iovs.06-1383] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To identify costimulatory molecules that are important in the effector phase of experimental autoimmune uveitis (EAU). METHODS EAU was induced in C57BL/6 (B6) mice by transfer of activated T cells specific for the interphotoreceptor-binding protein (IRBP) 1-20 peptide. The animals were then treated with and without anti-leukocyte function associated antigen (LFA)-1alpha mAb, at day 0 or 10 (disease onset) after T-cell transfer. Clinical signs of inflammation, ocular histology, and infiltrated inflammatory cells in the eye were compared. The primary and secondary proliferative responses of uveitogenic CD4 and CD8 T cells were tested after treatment with costimulatory blockers in vivo and in vitro. Moreover, the abilities of uveitogenic T cell trafficking and their interaction with retinal astrocytes were examined. RESULTS Anti-LFA-1alpha Abs caused significant suppression of disease when administered either at the time of effector uveitogenic T cell transfer or at disease onset. Studies of the mechanisms by which anti-LFA-1alpha Ab inhibits the effector phase of uveitis demonstrated that it blocks multiple pathogenic events of uveitis mediated by IRBP-specific uveitogenic T cells, including the activation of T cells outside and inside the eye and the trafficking of activated autoreactive T cells into the inflammatory site. In addition, Ab treatment selectively suppressed the activation and expansion of pathogenic, but not regulatory, T cells in vivo. CONCLUSIONS Anti-LFA-1alpha Abs are potent inhibitors of established autoimmune uveitis and that such treatment may be applicable not only for the prevention, but also the treatment, of T-cell-mediated autoimmune diseases.
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Affiliation(s)
- Yan Ke
- Department of Ophthalmology and Visual Sciences, Kentucky Lions Eye Center, University of Louisville, Louisville, Kentucky 40202, USA
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17
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Knop S, Hebart H, Gratwohl A, Kliem C, Faul C, Holler E, Apperley J, Kolb HJ, Schaefer A, Niederwieser D, Einsele H. Treatment of steroid-resistant acute GVHD with OKT3 and high-dose steroids results in better disease control and lower incidence of infectious complications when compared to high-dose steroids alone: a randomized multicenter trial by the EBMT Chronic Leukemia Working Party. Leukemia 2007; 21:1830-3. [PMID: 17495972 DOI: 10.1038/sj.leu.2404731] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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18
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Piñana JL, Valcárcel D, Martino R, Moreno ME, Sureda A, Briones J, Brunet S, Sierra J. Encouraging results with inolimomab (anti-IL-2 receptor) as treatment for refractory acute graft-versus-host disease. Biol Blood Marrow Transplant 2007; 12:1135-41. [PMID: 17085306 DOI: 10.1016/j.bbmt.2006.06.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 06/21/2006] [Indexed: 11/20/2022]
Abstract
Inolimomab [corrected] an anti-interleukin-2 receptor (anti-IL-2R) monoclonal antibody, may be useful in the treatment of steroid-refractory acute graft-versus-host disease (aGVHD) by inhibiting 1 of its putative immunopathogenic pathways. We retrospectively analyzed 40 consecutive patients who received inolimomab [corrected] as salvage treatment for steroid refractory aGVHD at a single institution between June 1999 and December 2004. Inolimomab [corrected] was given intravenously at a dose of 11 mg/d for 3 consecutive days, followed by 5.5 mg/d for 7 consecutive days and then 5.5 mg every other day for 5 doses. No infusion-related side effects were noted. Twenty-three patients (58%) responded, including 15 (38%) complete and 8 (20%) partial responses. Median overall survival was 294 days (58-996 days) for responders versus 14 days for nonresponders (P < .001), with a 1 year probability of 59% vs 0% for overall survival (P < .0001). Patients without gastrointestinal (GI) involvement showed a higher response rate (100% versus 50% for those without versus with GI involvement, P = .03) In addition, patients who showed some response by day 15 had a higher overall survival (73 +/- 12% vs 24 +/- 12%, respectively, P = .02). The results of this study suggest that inolimomab [corrected] may be an effective salvage therapy for patients with steroid-refractory aGVHD, particularly for those without GI disease, and supports further studies with this agent in prospective controlled trials.
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Affiliation(s)
- Jose Luis Piñana
- Division of Clinical Hematology, Hospital de la Santa Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
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19
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Baker KS, Ness KK, Steinberger J, Carter A, Francisco L, Burns LJ, Sklar C, Forman S, Weisdorf D, Gurney JG, Bhatia S. Diabetes, hypertension, and cardiovascular events in survivors of hematopoietic cell transplantation: a report from the bone marrow transplantation survivor study. Blood 2006; 109:1765-72. [PMID: 17047152 PMCID: PMC1794046 DOI: 10.1182/blood-2006-05-022335] [Citation(s) in RCA: 245] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
We ascertained the prevalence of self-reported late occurrence of diabetes, hypertension, and cardiovascular (CV) disease in 1089 hematopoietic cell transplantation (HCT) survivors who underwent HCT between 1974 and 1998, survived at least 2 years, and were not currently taking immunosuppressant agents and compared them with 383 sibling controls. All subjects completed a 255-item health questionnaire. The mean age at survey completion was 39.3 years for survivors and 38.6 years for siblings; mean follow-up was 8.6 years. Adjusting for age, sex, race, and body mass index (BMI), survivors of allogeneic HCT were 3.65 times (95% confidence interval [CI], 1.82-7.32) more likely to report diabetes than siblings and 2.06 times (95% CI, 1.39-3.04) more likely to report hypertension compared with siblings but did not report other CV outcomes with any greater frequency. Recipients of autologous HCTs were no more likely than siblings to report any of the outcomes studied. Allogeneic HCT survivors were also more likely to develop hypertension (odds ratio [OR]=2.31; 95% CI, 1.45-3.67) than autologous recipients. Total body irradiation (TBI) exposure was associated with an increased risk of diabetes (OR=3.42; 95% CI, 1.55-7.52). Thus, HCT survivors have a higher age- and BMI-adjusted risk of diabetes and hypertension, potentially leading to a higher than expected risk of CV events with age.
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Affiliation(s)
- K Scott Baker
- Department of Pediatrics, University of Minnesota, Minneapolis 55455, USA.
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20
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Georgantas RW, Bohana-Kashtan O, Civin CI. Ex Vivo Soluble Fas Ligand Treatment of Donor Cells to Selectively Reduce Murine Acute Graft Versus Host Disease. Transplantation 2006; 82:471-8. [PMID: 16926590 DOI: 10.1097/01.tp.0000229435.58898.c5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Allogeneic bone marrow transplantation (BMT) and donor lymphocyte infusion (DLI) provide valuable treatments for a range of diseases. However, the therapeutic utility of BMT and DLI is reduced by the high incidence of graft-versus-host disease (GvHD) mediated by activated donor T lymphocytes directed against recipient alloantigens. METHODS Using mouse models, we developed and evaluated a strategy to selectively enhance activation-induced cell death (AICD) of anti-recipient T cells within transplant donor cell populations, with the goal of reducing GvHD. Responder T lymphocytes were incubated ex vivo with irradiated allogenic stimulator cells in a mixed lymphocyte reaction (MLR) in the presence of soluble Fas ligand (sFasL) to induce AICD in alloreactive cells. RESULTS This ex vivo sFasL treatment reduced proliferation to the allogeneic stimulator cells in vitro and abrogated acute GvHD capacity in vivo. In contrast, the secondary immune responsiveness of the ex vivo sFasL-treated responder T cells to an unrelated model antigen was preserved. Furthermore, upon adoptive transfer in a DLI model, ex vivo sFasL-treated T cells were able to reject a model tumor. Finally, ex vivo sFasL treatment of bone marrow cells did not reduce their hematopoietic engraftment capacity. CONCLUSIONS Thus, ex vivo treatment with sFasL appears to have potential for translation to clinical cell processing of BMT allografts and DLI infusions.
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Affiliation(s)
- Robert W Georgantas
- Division of Immunology and Hematopoiesis, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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21
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Knoechel B, Lohr J, Kahn E, Bluestone JA, Abbas AK. Sequential development of interleukin 2-dependent effector and regulatory T cells in response to endogenous systemic antigen. ACTA ACUST UNITED AC 2005; 202:1375-86. [PMID: 16287710 PMCID: PMC2212975 DOI: 10.1084/jem.20050855] [Citation(s) in RCA: 246] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Transfer of naive antigen-specific CD4(+) T cells into lymphopenic mice that express an endogenous antigen as a systemic, secreted protein results in severe autoimmunity resembling graft-versus-host disease. T cells that respond to this endogenous antigen develop into effector cells that cause the disease. Recovery from this disease is associated with the subsequent generation of FoxP3(+)CD25(+) regulatory cells in the periphery. Both pathogenic effector cells and protective regulatory cells develop from the same antigen-specific T cell population after activation, and their generation may occur in parallel or sequentially. Interleukin (IL)-2 plays a dual role in this systemic T cell reaction. In the absence of IL-2, the acute disease is mild because of reduced T cell effector function, but a chronic and progressive disease develops late and is associated with a failure to generate FoxP3(+) regulatory T (T reg) cells in the periphery. Thus, a peripheral T cell reaction to a systemic antigen goes through a phase of effector cell-mediated pathology followed by T reg cell-mediated recovery, and both require the growth factor IL-2.
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Affiliation(s)
- Birgit Knoechel
- Department of Pathology, University of California, San Francisco, School of Medicine, CA 94143, USA
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22
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Dinauer N, Balthasar S, Weber C, Kreuter J, Langer K, von Briesen H. Selective targeting of antibody-conjugated nanoparticles to leukemic cells and primary T-lymphocytes. Biomaterials 2005; 26:5898-906. [PMID: 15949555 DOI: 10.1016/j.biomaterials.2005.02.038] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2004] [Accepted: 02/22/2005] [Indexed: 10/25/2022]
Abstract
In the present study, surface-modified nanoparticles based on biodegradable material were used for antibody coupling in order to get a selective drug carrier systems. Gelatin nanoparticles were prepared by a desolvation process. Sulfhydryl groups were introduced which enabled the linkage of NeutrAvidin (NAv). Antibodies specific for the CD3 antigen on lymphocytic cells were conjugated to the nanoparticles surface. The binding of biotinylated anti-CD3 antibody was achieved by NAv-biotin-complex formation. Cellular binding and uptake were determined by flow cytometry and confocal laser scanning microscopy (CLSM). Cell-type-specific targeting of anti-CD3-conjugated nanoparticles into CD3-positive human T-cell leukemia cells and primary T-lymphocytes could be shown. Celluar uptake and effective internalization of antibody-conjugated nanoparticles into CD3 expressing cells were demonstrated. Uptake rates of about 84% into T-cell leukemia cells were observed. To confirm selectivity of T-cell targeting, competition experiments were carried out adding excessive free anti-CD3 prior to nanoparticle incubation leading to significantly reduced cellular uptake of antibody-conjugated nanoparticles. Further analysis on the mechanism of uptake confirmed a receptor-mediated endocytotic process. Protein-based nanoparticles conjugated with an antibody against a specific cellular antigen hold promise as selective drug delivery systems for specific cell types.
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Affiliation(s)
- Norbert Dinauer
- Chemotherapeutische Forschungsinstitut Georg-Speyer-Haus, D-60596 Frankfurt, Germany
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23
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Abstract
Hematopoietic stem cell transplant (SCT) is considered standard therapy for a variety of malignant and nonmalignant diseases. Graft-versus-host disease (GVHD) still represents today a major complication of hematopoietic SCT. Two types of GVHD have traditionally been recognized on the basis of the time of onset following transplantation, distinct pathobiological pathways, and different clinical presentations. The acute form commonly breaks out 2 to 6 weeks after transplantation, affecting up to 60% of patients receiving allogeneic transplants from HLA identical donors. Transfer of immunocompetent donor T cells contained in the graft may undergo alloreactivity against recipient cells because of major or minor histocompatibility antigens disparities between the donor and the immunosuppressed host. Target specificity in acute GVHD involves preferential injury to epithelial surfaces of the skin and mucous membranes, biliary ducts of the liver, and crypts of the intestinal tract. Chronic GVHD affects approximately 30% to 80% of patients surviving 6 months or longer after stem cell transplantation and is the leading cause of nonrelapse deaths occurring more than 2 years after transplantation. Chronic GVHD is a multiorgan syndrome with clinical features suggesting some autoimmune diseases, and possibly both alloreactive and autoreactive T cell clones are involved in its pathophysiology. Although GVHD may convey beneficial graft-versus-leukemia/lymphoma effects, it also entails a significant risk of morbidity and mortality. Patients with mild GVHD need only minimal, if any, immunosuppressive treatment, whereas prognosis of patients with extensive disease or resistant to standard immunosuppressive treatment may be dismal. Early recognition of GVHD followed by prompt therapeutic intervention may prevent the progression to higher-grade disease and improve the outcome for patients receiving hematopoietic SCT.
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Affiliation(s)
- Erich Vargas-Díez
- Department of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain.
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24
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Auletta JJ, Lazarus HM. Immune restoration following hematopoietic stem cell transplantation: an evolving target. Bone Marrow Transplant 2005; 35:835-57. [PMID: 15778723 DOI: 10.1038/sj.bmt.1704966] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is the definitive cure for many malignant and nonmalignant diseases. However, delays in immune reconstitution (IR) following HSCT significantly limit the success of transplantation and increase the risk for infection and disease relapse in the transplant recipient. Therefore, ways to measure and to manipulate immune recovery following HSCT are emerging and their success depends directly upon an enhanced understanding for the underlying mechanisms responsible for reconstituted immunity and hematopoiesis. Recent discoveries in the activation, function, and regulation of dendritic cell (DC), natural killer (NK) cell, and T-lymphocyte subtypes have been critical in developing immunotherapies used to prevent graft-versus-host disease and to enhance graft-versus-leukemia. For example, regulatory T cells that induce tolerance and NK receptor-tumor ligand disparities that result in tumor lysis are being used to minimize GVHD and tumor burden, respectively. Furthermore, expansion and modulation of immune effector cells are being used to augment hematopoietic and immune recovery and to decrease transplant-related toxicity in the transplant recipient. Specifically, DC expansion and incorporation into antitumor and anti-microbial vaccines is fast approaching application into clinical trials. This paper will review our current understanding for IR following HSCT and the novel ways in which to restore immune function and decrease transplant-related toxicity in the transplant recipient.
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Affiliation(s)
- J J Auletta
- Comprehensive Cancer Center, Case Western Reserve University/University Hospitals of Cleveland, Cleveland, OH, USA.
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25
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Wandroo F, Auguston B, Cook M, Craddock C, Mahendra P. Successful use of Campath-1H in the treatment of steroid refractory liver GvHD. Bone Marrow Transplant 2005; 34:285-7. [PMID: 15170160 DOI: 10.1038/sj.bmt.1704573] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
MESH Headings
- Acute Disease
- Adult
- Alemtuzumab
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/therapeutic use
- Graft vs Host Disease/drug therapy
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/therapy
- Leukemia, Myeloid/immunology
- Leukemia, Myeloid/therapy
- Liver Diseases/drug therapy
- Male
- Stem Cell Transplantation/adverse effects
- Transplantation Chimera
- Transplantation, Homologous
- Treatment Outcome
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26
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Abstract
Mesenchymal stem cells (MSCs) are multipotent cells found in several adult tissues. Transplanted allogeneic MSCs can be detected in recipients at extended time points, indicating a lack of immune recognition and clearance. As well, a role for bone marrow-derived MSCs in reducing the incidence and severity of graft-versus-host disease (GVHD) during allogeneic transplantation has recently been reported; however, the mechanisms remain to be investigated. We examined the immunomodulatory functions of human MSCs (hMSCs) by coculturing them with purified subpopulations of immune cells and report here that hMSCs altered the cytokine secretion profile of dendritic cells (DCs), naive and effector T cells (T helper 1 [T(H)1] and T(H)2), and natural killer (NK) cells to induce a more anti-inflammatory or tolerant phenotype. Specifically, the hMSCs caused mature DCs type 1 (DC1) to decrease tumor necrosis factor alpha (TNF-alpha) secretion and mature DC2 to increase interleukin-10 (IL-10) secretion; hMSCs caused T(H)1 cells to decrease interferon gamma (IFN-gamma) and caused the T(H)2 cells to increase secretion of IL-4; hMSCs caused an increase in the proportion of regulatory T cells (T(Regs)) present; and hMSCs decreased secretion of IFN-gamma from the NK cells. Mechanistically, the hMSCs produced elevated prostaglandin E2 (PGE(2)) in co-cultures, and inhibitors of PGE(2) production mitigated hMSC-mediated immune modulation. These data offer insight into the interactions between allogeneic MSCs and immune cells and provide mechanisms likely involved with the in vivo MSC-mediated induction of tolerance that could be therapeutic for reduction of GVHD, rejection, and modulation of inflammation.
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27
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Affiliation(s)
- Anita C Gilliam
- Department of Dermatology Case/University Hopsitals of Cleveland Cleveland, Ohio, USA
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28
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Srinivasan R, Chakrabarti S, Walsh T, Igarashi T, Takahashi Y, Kleiner D, Donohue T, Shalabi R, Carvallo C, Barrett AJ, Geller N, Childs R. Improved survival in steroid-refractory acute graft versus host disease after non-myeloablative allogeneic transplantation using a daclizumab-based strategy with comprehensive infection prophylaxis. Br J Haematol 2004; 124:777-86. [PMID: 15009066 DOI: 10.1111/j.1365-2141.2004.04856.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Approximately 15% of patients undergoing non-myeloablative allogeneic haematopoietical cell transplantation (NMHCT) develop steroid-refractory acute-graft versus host disease (aGVHD), a usually fatal complication. We encountered 18 cases of steroid-refractory aGVHD in 146 patients, undergoing NMHCT from a related human leucocyte antigen-compatible donor following cyclophosphamide/fludarabine-based conditioning. Our initial cohort of steroid-refractory aGVHD patients treated with antithymocyte globulin (ATG) and mycophenolate mofetil (regimen-1: n = 6) had high GVHD-related mortality. Therefore, we investigated an alternative strategy for subsequent patients developing this complication (regimen-2: n = 12), consisting of daclizumab (alone or combined with infliximab/ATG) and targeted broad spectrum antibacterial and aspergillus prophylaxis in conjunction with rapid tapering of steroids to minimize opportunistic infections. In a retrospective analysis, patients receiving regimen-2 were significantly more likely to have complete resolution of GVHD compared with those receiving regimen-1 [12/12 (100%) vs. 1/6 (17%); P < 0.001]. When compared with those receiving regimen-1, regimen-2 patients also had a higher probability of survival at day 100 (100% vs. 50%) and day 200 (73% vs. 17%) post-transplant, and improved overall survival (median 453 d vs. 42 d from aGVHD onset; P < 0.0001). GVHD-related mortality was 89% for regimen-1 patients vs. 17% for regimen-2 patients (P < 0.0001). These data suggest that a co-ordinated approach using immunoregulatory monoclonal antibodies, pre-emptive antimicrobial therapy and judicious steroid withdrawal can dramatically improve outcome in steroid-refractory aGVHD.
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Affiliation(s)
- R Srinivasan
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1652, USA
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