1
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Cao Y, Gong X, Feng Y, Wang M, Hu Y, Liu H, Liu X, Qi S, Ji Y, Liu F, Zhu H, Guo W, Shen Q, Zhang R, Zhao N, Zhai W, Song X, Chen X, Geng L, Chen X, Zheng X, Ma Q, Tang B, Wei J, Huang Y, Ren Y, Song K, Yang D, Pang A, Yao W, He Y, Shang Y, Wan X, Zhang W, Zhang S, Sun G, Feng S, Zhu X, Han M, Song Z, Guo Y, Sun Z, Jiang E, Chen J. The Composite Immune Risk Score predicts overall survival after allogeneic hematopoietic stem cell transplantation: A retrospective analysis of 1838 cases. Am J Hematol 2023; 98:309-321. [PMID: 36591789 PMCID: PMC10108217 DOI: 10.1002/ajh.26792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 01/03/2023]
Abstract
There has been little consensus on how to quantitatively assess immune reconstitution after hematopoietic stem cell transplantation (HSCT) as part of the standard of care. We retrospectively analyzed 11 150 post-transplant immune profiles of 1945 patients who underwent HSCT between 2012 and 2020. 1838 (94.5%) of the cases were allogeneic HSCT. Using the training set of patients (n = 729), we identified a composite immune signature (integrating neutrophil, total lymphocyte, natural killer, total T, CD4+ T, and B cell counts in the peripheral blood) during days 91-180 after allogeneic HSCT that was predictive of early mortality and moreover simplified it into a formula for a Composite Immune Risk Score. When we verified the Composite Immune Risk Score in the validation (n = 284) and test (n = 391) sets of patients, a high score value was found to be associated with hazard ratios (HR) of 3.64 (95% C.I. 1.55-8.51; p = .0014) and 2.44 (95% C.I., 1.22-4.87; p = .0087), respectively, for early mortality. In multivariate analysis, a high Composite Immune Risk Score during days 91-180 remained an independent risk factor for early mortality after allogeneic HSCT (HR, 1.80; 95% C.I., 1.28-2.55; p = .00085). In conclusion, the Composite Immune Risk Score is easy to compute and could identify the high-risk patients of allogeneic HSCT who require targeted effort for prevention and control of infection.
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Affiliation(s)
- Yigeng Cao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaowen Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Yahui Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Mingyang Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Yu Hu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Huilan Liu
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China.,Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, Anhui Provincial Key Laboratory of Blood Research and Applications, University of Science and Technology of China, Hefei, China
| | - Xueou Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Saibing Qi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Yanping Ji
- Anhui Medical University, Hefei, China.,Department of Hematology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Fang Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Huaiping Zhu
- Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, Anhui Provincial Key Laboratory of Blood Research and Applications, University of Science and Technology of China, Hefei, China
| | - Wenwen Guo
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Qiujin Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Rongli Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Ningning Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Weihua Zhai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaoqiang Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Xin Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Liangquan Geng
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Xia Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Xuetong Zheng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Qiaoling Ma
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Baolin Tang
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Yong Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Yuanyuan Ren
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Kaidi Song
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Aiming Pang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Wen Yao
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Yue Shang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Xiang Wan
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Wei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Song Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Guangyu Sun
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Zhen Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Ye Guo
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Zimin Sun
- Department of Hematology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China.,Blood and Cell Therapy Institute, Division of Life Sciences and Medicine, Anhui Provincial Key Laboratory of Blood Research and Applications, University of Science and Technology of China, Hefei, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
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2
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Peinelt A, Bremm M, Kreyenberg H, Cappel C, Banisharif-Dehkordi J, Erben S, Rettinger E, Jarisch A, Meisel R, Schlegel PG, Beck O, Bug G, Klusmann JH, Klingebiel T, Huenecke S, Bader P. Monitoring of Circulating CAR T Cells: Validation of a Flow Cytometric Assay, Cellular Kinetics, and Phenotype Analysis Following Tisagenlecleucel. Front Immunol 2022; 13:830773. [PMID: 35309367 PMCID: PMC8926389 DOI: 10.3389/fimmu.2022.830773] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/11/2022] [Indexed: 12/20/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy is a potent new treatment option for relapsed or refractory hematologic malignancies. As the monitoring of CAR T cell kinetics can provide insights into the activity of the therapy, appropriate CAR T cell detection methods are essential. Here, we report on the comprehensive validation of a flow cytometric assay for peripheral blood CD19 CAR T cell detection. Further, a retrospective analysis (n = 30) of CAR T cell and B cell levels over time has been performed, and CAR T cell phenotypes have been characterized. Serial dilution experiments demonstrated precise and linear quantification down to 0.05% of T cells or 22 CAR T cell events. The calculated detection limit at 13 events was confirmed with CAR T cell negative control samples. Inter-method comparison with real-time PCR showed appreciable correlation. Stability testing revealed diminished CAR T cell values already one day after sample collection. While we found long-term CAR T cell detectability and B cell aplasia in most patients (12/17), some patients (5/17) experienced B cell recovery. In three of these patients the coexistence of CAR T cells and regenerating B cells was observed. Repeat CAR T cell infusions led to detectable but limited re-expansions. Comparison of CAR T cell subsets with their counterparts among all T cells showed a significantly higher percentage of effector memory T cells and a significantly lower percentage of naïve T cells and T EMRA cells among CAR T cells. In conclusion, flow cytometric CAR T cell detection is a reliable method to monitor CAR T cells if measurements start without delay and sufficient T cell counts are given.
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Affiliation(s)
- Andreas Peinelt
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Melanie Bremm
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Hermann Kreyenberg
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Claudia Cappel
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Julia Banisharif-Dehkordi
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Stephanie Erben
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Eva Rettinger
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Andrea Jarisch
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Roland Meisel
- Division of Pediatric Stem Cell Therapy, Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich-Heine-University, Duesseldorf, Germany
| | - Paul-Gerhardt Schlegel
- Department of Pediatric Hematology and Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Olaf Beck
- Department of Pediatric Hematology/Oncology, Center for Pediatric and Adolescent Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Gesine Bug
- Hematology/Oncology, Department of Internal Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Jan-Henning Klusmann
- Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Thomas Klingebiel
- Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Sabine Huenecke
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Peter Bader
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany.,Department of Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
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3
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Spadea M, Saglio F, Tripodi SI, Menconi M, Zecca M, Fagioli F. Multivariate Analysis of Immune Reconstitution and Relapse Risk Scoring in Children Receiving Allogeneic Stem Cell Transplantation for Acute Leukemias. Transplant Direct 2021; 7:e774. [PMID: 34646937 PMCID: PMC8500617 DOI: 10.1097/txd.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/13/2021] [Indexed: 11/25/2022] Open
Abstract
A timely and effective immune reconstitution after hematopoietic stem cell transplantation (HSCT) is of crucial importance to enhance graft-versus-leukemia reaction in hematological malignancies. Several factors can influence the yield of this process, and new mathematical models are needed to describe this complex phenomenon.
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Affiliation(s)
- Manuela Spadea
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Francesco Saglio
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
| | - Serena I Tripodi
- Pediatric Hematology-Oncology, Fondazione Istituti di ricovero e cura a carattere scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Mariacristina Menconi
- Haematopoietic Stem Cell Transplantation Unit, Paediatric Clinic, University Hospital of Pisa, Pisa, Italy
| | - Marco Zecca
- Pediatric Hematology-Oncology, Fondazione Istituti di ricovero e cura a carattere scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Franca Fagioli
- Pediatric Oncohematology, Stem Cell Transplantation and Cell Therapy Division, A.O.U. Città della Salute e della Scienza-Regina Margherita Children's Hospital, Turin, Italy
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4
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Yanir A, Schulz A, Lawitschka A, Nierkens S, Eyrich M. Immune Reconstitution After Allogeneic Haematopoietic Cell Transplantation: From Observational Studies to Targeted Interventions. Front Pediatr 2021; 9:786017. [PMID: 35087775 PMCID: PMC8789272 DOI: 10.3389/fped.2021.786017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/13/2021] [Indexed: 12/20/2022] Open
Abstract
Immune reconstitution (IR) after allogeneic haematopoietic cell transplantation (HCT) represents a central determinant of the clinical post-transplant course, since the majority of transplant-related outcome parameters such as graft-vs.-host disease (GvHD), infectious complications, and relapse are related to the velocity, quantity and quality of immune cell recovery. Younger age at transplant has been identified as the most important positive prognostic factor for favourable IR post-transplant and, indeed, accelerated immune cell recovery in children is most likely the pivotal contributing factor to lower incidences of GvHD and infectious complications in paediatric allogeneic HCT. Although our knowledge about the mechanisms of IR has significantly increased over the recent years, strategies to influence IR are just evolving. In this review, we will discuss different patterns of IR during various time points post-transplant and their impact on outcome. Besides IR patterns and cellular phenotypes, recovery of antigen-specific immune cells, for example virus-specific T cells, has recently gained increasing interest, as certain threshold levels of antigen-specific T cells seem to confer protection against severe viral disease courses. In contrast, the association between IR and a possible graft-vs. leukaemia effect is less well-understood. Finally, we will present current concepts of how to improve IR and how this could change transplant procedures in the near future.
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Affiliation(s)
- Asaf Yanir
- Bone Marrow Transplant Unit, Division of Haematology and Oncology, Schneider Children's Medical Center of Israel, Petach-Tikva, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Ansgar Schulz
- Department of Pediatrics, University Medical Center Ulm, Ulm, Germany
| | - Anita Lawitschka
- St. Anna Children's Hospital, Medical University of Vienna, Vienna, Austria.,St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Stefan Nierkens
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Matthias Eyrich
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University Children's Hospital, University Medical Center, University of Würzburg, Würzburg, Germany
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5
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Diana JS, Bouazza N, Couzin C, Castelle M, Magnani A, Magrin E, Rosain J, Treluyer JM, Picard C, Moshous D, Blanche S, Neven B, Cavazzana M. Bayesian Modeling Immune Reconstitution Apply to CD34+ Selected Stem Cell Transplantation for Severe Combined Immunodeficiency. Front Pediatr 2021; 9:804912. [PMID: 35242727 PMCID: PMC8885722 DOI: 10.3389/fped.2021.804912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
Severe combined immunodeficiencies (SCIDs) correspond to the most severe form of primary immunodeficiency. Allogeneic hematopoietic stem cell transplantation (HSCT) and gene therapy are curative treatments, depending on the donor's availability and molecular diagnostics. A partially human leukocyte antigen (HLA)-compatible donor used has been developed for this specific HSCT indication in the absence of a matched donor. However, the CD34+ selected process induces prolonged post-transplant T-cell immunodeficiency. The aim here was to investigate a modeling approach to predict the time course and the extent of CD4+ T-cell immune reconstitution after CD34+ selected transplantation. We performed a Bayesian approach based on the age-related changes in thymic output and the cell proliferation/loss model. For that purpose, we defined specific individual covariates from the data collected from 10 years of clinical practice and then evaluated the model's predicted performances and accuracy. We have shown that this Bayesian modeling approach predicted the time course and extent of CD4+ T-cell immune reconstitution after SCID transplantation.
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Affiliation(s)
- Jean-Sebastien Diana
- Biotherapy Department, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université de Paris, Paris, France
| | - Naïm Bouazza
- Université de Paris, Paris, France.,Clinical Research Unit, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Chloe Couzin
- Biotherapy Department, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Martin Castelle
- Pediatric Hematology-Immunology-Rheumatology Unit, Hôpital Necker Enfants Malades Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alessandra Magnani
- Biotherapy Department, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Elisa Magrin
- Biotherapy Department, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jeremie Rosain
- Laboratory of Human Genetics of Infectious Diseases, Hôpital Necker Enfants Malades Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jean-Marc Treluyer
- Université de Paris, Paris, France.,Clinical Research Unit, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Capucine Picard
- Université de Paris, Paris, France.,Laboratory of Human Genetics of Infectious Diseases, Hôpital Necker Enfants Malades Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Despina Moshous
- Université de Paris, Paris, France.,Pediatric Hematology-Immunology-Rheumatology Unit, Hôpital Necker Enfants Malades Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Stéphane Blanche
- Université de Paris, Paris, France.,Pediatric Hematology-Immunology-Rheumatology Unit, Hôpital Necker Enfants Malades Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bénédicte Neven
- Université de Paris, Paris, France.,Pediatric Hematology-Immunology-Rheumatology Unit, Hôpital Necker Enfants Malades Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marina Cavazzana
- Biotherapy Department, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France.,Université de Paris, Paris, France
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6
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Lambert C, Yanikkaya Demirel G, Keller T, Preijers F, Psarra K, Schiemann M, Özçürümez M, Sack U. Flow Cytometric Analyses of Lymphocyte Markers in Immune Oncology: A Comprehensive Guidance for Validation Practice According to Laws and Standards. Front Immunol 2020; 11:2169. [PMID: 33042129 PMCID: PMC7528430 DOI: 10.3389/fimmu.2020.02169] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/10/2020] [Indexed: 12/12/2022] Open
Abstract
Many anticancer therapies such as antibody-based therapies, cellular therapeutics (e.g., genetically modified cells, regulators of cytokine signaling, and signal transduction), and other biologically tailored interventions strongly influence the immune system and require tools for research, diagnosis, and monitoring. In flow cytometry, in vitro diagnostic (IVD) test kits that have been compiled and validated by the manufacturer are not available for all requirements. Laboratories are therefore usually dependent on modifying commercially available assays or, most often, developing them to meet clinical needs. However, both variants must then undergo full validation to fulfill the IVD regulatory requirements. Flow cytometric immunophenotyping is a multiparametric analysis of parameters, some of which have to be repeatedly adjusted; that must be considered when developing specific antibody panels. Careful adjustments of general rules are required to meet legal and regulatory requirements in the analysis of these assays. Here, we describe the relevant regulatory framework for flow cytometry-based assays and describe methods for the introduction of new antibody combinations into routine work including development of performance specifications, validation, and statistical methodology for design and analysis of the experiments. The aim is to increase reliability, efficiency, and auditability after the introduction of in-house-developed flow cytometry assays.
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Affiliation(s)
- Claude Lambert
- University Hospital, Immunology Laboratory, FRE-CNRS 3312, Saint-Etienne, France
| | | | | | - Frank Preijers
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Katherina Psarra
- Department of Immunology-Histocompatibility, Evangelismos Hospital, Athens, Greece
| | - Matthias Schiemann
- Institute for Medical Microbiology, Immunology and Hygiene, Technische Universität München, Munich, Germany
| | - Mustafa Özçürümez
- Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Ulrich Sack
- Medizinische Fakultät, Institut für Klinische Immunologie, Universität Leipzig, Leipzig, Germany
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7
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Merker M, Meister MT, Heinze A, Jarisch A, Sörensen J, Huenecke S, Bremm M, Cappel C, Klingebiel T, Bader P, Rettinger E. Adoptive cellular immunotherapy for refractory childhood cancers: a single center experience. Oncotarget 2019; 10:6138-6151. [PMID: 31692914 PMCID: PMC6817438 DOI: 10.18632/oncotarget.27242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 09/10/2019] [Indexed: 12/31/2022] Open
Abstract
Prognosis of refractory childhood cancers despite multimodal treatment strategies remains poor. Here, we report a single center experience encountered in 18 patients with refractory solid malignancies treated with adoptive cellular immunotherapy (ACI) from haploidentical or matched donors following hematopoietic stem cell transplantation. While seven patients were in partial and six in complete remission (CR), five patients suffered from relapsed diseases at the time of ACI. 1.5-year probabilities of overall survival (OS) and progression-free survival (PFS) were 19.5% and 16.1% for all patients. Patients in CR showed estimated 1.5-year OS and PFS of 50.1% and 42.7%, respectively. CR was induced or rather sustained in ten children, with two still being alive 9.6 and 9.3 years after ACI. Naïve, central and effector memory T-cells correlated with responses. However, the majority of patients relapsed. Cumulative incidence of relapse was 79.8% at 1.5 years. Acute graft versus host disease (aGVHD) occurred in nine of 18 patients (50%) with aGVHD grade I–II observed in six (33%) and aGVHD grade III seen in three (17%) patients, manageable in all cases. Altogether, study results indicate that donor-derived ACI at its current state offers palliation but no clear curative benefit for refractory childhood cancers and warrants further improvement.
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Affiliation(s)
- Michael Merker
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Michael Torsten Meister
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Annekathrin Heinze
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Andrea Jarisch
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Jan Sörensen
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Sabine Huenecke
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Melanie Bremm
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Claudia Cappel
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Thomas Klingebiel
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Peter Bader
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
| | - Eva Rettinger
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescent Medicine, University Hospital Frankfurt, JW Goethe University, Frankfurt am Main, Germany
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8
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Mellgren K, Nierop AF, Abrahamsson J. Use of Multivariate Immune Reconstitution Patterns to Describe Immune Reconstitution after Allogeneic Stem Cell Transplantation in Children. Biol Blood Marrow Transplant 2019; 25:2045-2053. [DOI: 10.1016/j.bbmt.2019.06.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 05/08/2019] [Accepted: 06/19/2019] [Indexed: 01/12/2023]
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9
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Merker M, Salzmann-Manrique E, Katzki V, Huenecke S, Bremm M, Bakhtiar S, Willasch A, Jarisch A, Soerensen J, Schulz A, Meisel R, Bug G, Bonig H, Klingebiel T, Bader P, Rettinger E. Clearance of Hematologic Malignancies by Allogeneic Cytokine-Induced Killer Cell or Donor Lymphocyte Infusions. Biol Blood Marrow Transplant 2019; 25:1281-1292. [PMID: 30878607 DOI: 10.1016/j.bbmt.2019.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/06/2019] [Indexed: 11/18/2022]
Abstract
Well-established donor lymphocyte infusion (DLI) and novel cytokine-induced killer (CIK) cell therapy for the treatment of relapsing hematologic malignancies after allogeneic hematopoietic stem cell transplantation (HSCT) were compared with respect to feasibility, safety, and efficacy. Altogether, a total of 221 infusions were given to 91 patients (DLI, n = 55; CIK, n = 36). T cell recovery was significantly improved after CIK cell therapy (P < .0001). Although patients with CIK cell treatment showed a significantly worse prognosis at the time of HSCT (risk score, 1.7 versus 2.1; P < .0001), DLI and CIK cell therapy induced complete remission (CR) in 29% and 53% patients, respectively, whereas relapse occurred in 71% and 47%. In both groups, all patients with overt hematologic relapse at the time of immunotherapy (DLI, n = 11; CIK, n = 8) succumbed to their disease, while 36% and 68% patients with DLI or CIK cell therapy applied due to molecular relapse or active disease at the time of transplantation achieved CR. The 6-month overall survival rate in the latter patients was 57% and 77%, respectively, with a median follow-up of 27.9 months (range, .9 to 149.2 months). The 6-month cumulative incidence of relapse was 55% and 22% in patients who received DLI and CIK cell therapy, respectively (P = .012). Acute graft-versus-host disease developed in 35% of the patients who received DLI and in 25% of those who received CIK. No transfusion-related deaths occurred. These data, while underscoring the therapeutic value of conventional DLI, suggest the improved safety and to a certain extent efficacy of CIK cell therapy for patients at high risk for post-transplantation relapse of various hematologic malignancies.
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Affiliation(s)
- Michael Merker
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Emilia Salzmann-Manrique
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Verena Katzki
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Sabine Huenecke
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Melanie Bremm
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Shahrzad Bakhtiar
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Andre Willasch
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Andrea Jarisch
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Jan Soerensen
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Ansgar Schulz
- Pediatric Oncology, Department of Pediatric and Adolescent Medicine, University Hospital Ulm, Ulm, Germany
| | - Roland Meisel
- Clinic of Pediatric Oncology, Hematology and Immunology, University Children's Hospital Düsseldorf, Düsseldorf, Germany
| | - Gesine Bug
- Hematology/Oncology, Department of Internal Medicine, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Halvard Bonig
- German Red Cross Blood Donor Service Baden-Württemberg-Hessen and Institute for Transfusion Medicine and Immunohematology, Department of Cellular Therapeutics/Cell Processing, Goethe University Frankfurt, Frankfurt am Main, Germany; Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington
| | - Thomas Klingebiel
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Peter Bader
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Eva Rettinger
- Division of Stem Cell Transplantation and Immunology, Department of Children and Adolescents, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany.
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10
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Salzmann-Manrique E, Bremm M, Huenecke S, Stech M, Orth A, Eyrich M, Schulz A, Esser R, Klingebiel T, Bader P, Herrmann E, Koehl U. Joint Modeling of Immune Reconstitution Post Haploidentical Stem Cell Transplantation in Pediatric Patients With Acute Leukemia Comparing CD34 +-Selected to CD3/CD19-Depleted Grafts in a Retrospective Multicenter Study. Front Immunol 2018; 9:1841. [PMID: 30154788 PMCID: PMC6102342 DOI: 10.3389/fimmu.2018.01841] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 07/26/2018] [Indexed: 12/25/2022] Open
Abstract
Rapid immune reconstitution (IR) following stem cell transplantation (SCT) is essential for a favorable outcome. The optimization of graft composition should not only enable a sufficient IR but also improve graft vs. leukemia/tumor effects, overcome infectious complications and, finally, improve patient survival. Especially in haploidentical SCT, the optimization of graft composition is controversial. Therefore, we analyzed the influence of graft manipulation on IR in 40 patients with acute leukemia in remission. We examined the cell recovery post haploidentical SCT in patients receiving a CD34+-selected or CD3/CD19-depleted graft, considering the applied conditioning regimen. We used joint model analysis for overall survival (OS) and analyzed the dynamics of age-adjusted leukocytes; lymphocytes; monocytes; CD3+, CD3+CD4+, and CD3+CD8+ T cells; natural killer (NK) cells; and B cells over the course of time after SCT. Lymphocytes, NK cells, and B cells expanded more rapidly after SCT with CD34+-selected grafts (P = 0.036, P = 0.002, and P < 0.001, respectively). Contrarily, CD3+CD4+ helper T cells recovered delayer in the CD34 selected group (P = 0.026). Furthermore, reduced intensity conditioning facilitated faster immune recovery of lymphocytes and T cells and their subsets (P < 0.001). However, the immune recovery for NK cells and B cells was comparable for patients who received reduced-intensity or full preparative regimens. Dynamics of all cell types had a significant influence on OS, which did not differ between patients receiving CD34+-selected and those receiving CD3/CD19-depleted grafts. In conclusion, cell reconstitution dynamics showed complex diversity with regard to the graft manufacturing procedure and conditioning regimen.
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Affiliation(s)
- Emilia Salzmann-Manrique
- Department of Medicine, Institute of Biostatistics and Mathematical Modeling, Johann Wolfgang Goethe-University, Frankfurt, Germany.,Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Melanie Bremm
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Sabine Huenecke
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Milena Stech
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andreas Orth
- University of Applied Sciences Frankfurt, Frankfurt, Germany
| | - Matthias Eyrich
- Pediatric Hematology and Oncology, University of Wuerzburg, Wuerzburg, Germany
| | - Ansgar Schulz
- Pediatric Hematology and Oncology, University of Ulm, Ulm, Germany
| | - Ruth Esser
- Institute of Cellular Therapeutics Hannover Medical School, Hannover, Germany
| | - Thomas Klingebiel
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Peter Bader
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modeling, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Ulrike Koehl
- Institute of Cellular Therapeutics Hannover Medical School, Hannover, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany.,Fraunhofer Institute of Cellular Therapy and Immunology, Leipzig, Germany
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11
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Huenecke S, Cappel C, Esser R, Pfirrmann V, Salzmann-Manrique E, Betz S, Keitl E, Banisharif-Dehkordi J, Bakhtiar S, Königs C, Jarisch A, Soerensen J, Ullrich E, Klingebiel T, Bader P, Bremm M. Development of Three Different NK Cell Subpopulations during Immune Reconstitution after Pediatric Allogeneic Hematopoietic Stem Cell Transplantation: Prognostic Markers in GvHD and Viral Infections. Front Immunol 2017; 8:109. [PMID: 28239380 PMCID: PMC5300968 DOI: 10.3389/fimmu.2017.00109] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/23/2017] [Indexed: 02/03/2023] Open
Abstract
Natural killer (NK) cells play an important role following allogeneic hematopoietic stem cell transplantation (HSCT) exerting graft-versus-leukemia/tumor effect and mediating pathogen-specific immunity. Although NK cells are the first donor-derived lymphocytes reconstituting post-HSCT, their distribution of CD56++CD16- (CD56bright), CD56++CD16+ (CD56intermediate=int), and CD56+CD16++ (CD56dim) NK cells is explicitly divergent from healthy adults, but to some extent comparable to the NK cell development in early childhood. The proportion of CD56bright/CD56int/CD56dim changed from 15/8/78% in early childhood to 6/4/90% in adults, respectively. Within this study, we first compared the NK cell reconstitution post-HSCT to reference values of NK cell subpopulations of healthy children. Afterward, we investigated the reconstitution of NK cell subpopulations post-HSCT in correlation to acute graft versus host disease (aGvHD) and chronic graft versus host disease (cGvHD) as well as to viral infections. Interestingly, after a HSCT follow-up phase of 12 months, the distribution of NK cell subpopulations largely matched the 50th percentile of the reference range for healthy individuals. Patients suffering from aGvHD and cGvHD showed a delayed reconstitution of NK cells. Remarkably, within the first 2 months post-HSCT, patients suffering from aGvHD had significantly lower levels of CD56bright NK cells compared to patients without viral infection or without graft versus host disease (GvHD). Therefore, the amount of CD56bright NK cells might serve as an early prognostic factor for GvHD development. Furthermore, a prolonged and elevated peak in CD56int NK cells seemed to be characteristic for the chronification of GvHD. In context of viral infection, a slightly lower CD56 and CD16 receptor expression followed by a considerable reduction in the absolute CD56dim NK cell numbers combined with reoccurrence of CD56int NK cells was observed. Our results suggest that a precise analysis of the reconstitution of NK cell subpopulations post-HSCT might indicate the occurrence of undesired events post-HSCT such as severe aGvHD.
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Affiliation(s)
- Sabine Huenecke
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Claudia Cappel
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Ruth Esser
- GMP Development Unit, Hannover Medical School, Institute of Cellular Therapeutics , Hannover , Germany
| | - Verena Pfirrmann
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | | | - Sibille Betz
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Eileen Keitl
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | | | - Shahrzad Bakhtiar
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Christoph Königs
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Andrea Jarisch
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Jan Soerensen
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Evelyn Ullrich
- Clinic for Pediatric and Adolescent Medicine, University Hospital, Frankfurt, Germany; LOEWE Center for Cell and Gene Therapy, Goethe University, Frankfurt, Germany
| | - Thomas Klingebiel
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Peter Bader
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
| | - Melanie Bremm
- Clinic for Pediatric and Adolescent Medicine, University Hospital , Frankfurt , Germany
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12
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Pre-Emptive Immunotherapy for Clearance of Molecular Disease in Childhood Acute Lymphoblastic Leukemia after Transplantation. Biol Blood Marrow Transplant 2016; 23:87-95. [PMID: 27742575 DOI: 10.1016/j.bbmt.2016.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/07/2016] [Indexed: 12/21/2022]
Abstract
Monitoring of minimal residual disease (MRD) or chimerism may help guide pre-emptive immunotherapy (IT) with a view to preventing relapse in childhood acute lymphoblastic leukemia (ALL) after transplantation. Patients with ALL who consecutively underwent transplantation in Frankfurt/Main, Germany between January 1, 2005 and July 1, 2014 were included in this retrospective study. Chimerism monitoring was performed in all, and MRD assessment was performed in 58 of 89 patients. IT was guided in 19 of 24 patients with mixed chimerism (MC) and MRD and by MRD only in another 4 patients with complete chimerism (CC). The 3-year probabilities of event-free survival (EFS) were .69 ± .06 for the cohort without IT and .69 ± .10 for IT patients. Incidences of relapse (CIR) and treatment-related mortality (CITRM) were equally distributed between both cohorts (without IT: 3-year CIR, .21 ± .05, 3-year CITRM, .10 ± .04; IT patients: 3-year CIR, .18 ± .09, 3-year CITRM .13 ± .07). Accordingly, 3-year EFS and 3-year CIR were similar in CC and MC patients with IT, whereas MC patients without IT experienced relapse. IT was neither associated with an enhanced immune recovery nor an increased risk for acute graft-versus-host disease. Relapse prevention by IT in patients at risk may lead to the same favorable outcome as found in CC and MRD-negative-patients. This underlines the importance of excellent MRD and chimerism monitoring after transplantation as the basis for IT to improve survival in childhood ALL.
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13
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Dandoy CE, Hariharan S, Weiss B, Demmel K, Timm N, Chiarenzelli J, Dewald MK, Kennebeck S, Langworthy S, Pomales J, Rineair S, Sandfoss E, Volz-Noe P, Nagarajan R, Alessandrini E. Sustained reductions in time to antibiotic delivery in febrile immunocompromised children: results of a quality improvement collaborative. BMJ Qual Saf 2015; 25:100-9. [DOI: 10.1136/bmjqs-2015-004451] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/05/2015] [Indexed: 11/04/2022]
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14
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Patterns of monocyte subpopulations and their surface expression of HLA-DR during adverse events after hematopoietic stem cell transplantation. Ann Hematol 2014; 94:825-36. [DOI: 10.1007/s00277-014-2287-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/18/2014] [Indexed: 12/24/2022]
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15
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Elze MC, Ciocarlie O, Heinze A, Kloess S, Gardlowski T, Esser R, Klingebiel T, Bader P, Huenecke S, Serban M, Köhl U, Hutton JL. Dendritic cell reconstitution is associated with relapse-free survival and acute GVHD severity in children after allogeneic stem cell transplantation. Bone Marrow Transplant 2014; 50:266-73. [PMID: 25387093 DOI: 10.1038/bmt.2014.257] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 09/25/2014] [Accepted: 09/25/2014] [Indexed: 12/19/2022]
Abstract
DCs are potent APCs and key regulators of innate and adaptive immunity. After allo-SCT, their reconstitution in the peripheral blood (PB) to levels similar to those in healthy individuals tends to be slow. We investigate the age- and sex-dependant immune reconstitution of myeloid (mDC) and plasmacytoid DC (pDC) in the PB of 45 children with leukaemia or myelodysplastic syndrome (aged 1-17 years, median 10) after allo-SCT with regard to relapse, acute GVHD (aGVHD) and relapse-free survival. Low pDC/μL PB up to day 60 post SCT are associated with higher incidence of moderate or severe aGVHD (P=0.035), whereas high pDC/μL PB up to day 60 are associated with higher risk of relapse (P<0.001). The time-trend of DCs/μL PB for days 0-200 is a significant predictor of relapse-free survival for both mDCs (P<0.001) and pDCs (P=0.020). Jointly modelling DC reconstitution and complications improves on these simple criteria. Compared with BM, PBSC transplants tend to show slower mDC/pDC reconstitution (P=0.001, 0.031, respectively), but have no direct effect on relapse-free survival. These results suggest an important role for both mDCs and pDCs in the reconstituting immune system. The inclusion of mDCs and pDCs may improve existing models for complication prediction following allo-SCT.
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Affiliation(s)
- M C Elze
- Department of Statistics, University of Warwick, Coventry, UK
| | - O Ciocarlie
- 1] Institute of Cellular Therapeutics, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Germany [2] Paediatrics Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - A Heinze
- Pediatrics Department, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - S Kloess
- Institute of Cellular Therapeutics, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Germany
| | - T Gardlowski
- Institute of Cellular Therapeutics, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Germany
| | - R Esser
- Institute of Cellular Therapeutics, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Germany
| | - T Klingebiel
- Pediatrics Department, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - P Bader
- Pediatrics Department, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - S Huenecke
- Pediatrics Department, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - M Serban
- Paediatrics Department, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania
| | - U Köhl
- Institute of Cellular Therapeutics, Integrated Research and Treatment Center Transplantation, Hannover Medical School, Hannover, Germany
| | - J L Hutton
- Department of Statistics, University of Warwick, Coventry, UK
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16
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Barker CIS, Germovsek E, Hoare RL, Lestner JM, Lewis J, Standing JF. Pharmacokinetic/pharmacodynamic modelling approaches in paediatric infectious diseases and immunology. Adv Drug Deliv Rev 2014; 73:127-39. [PMID: 24440429 PMCID: PMC4076844 DOI: 10.1016/j.addr.2014.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 12/09/2013] [Accepted: 01/11/2014] [Indexed: 02/02/2023]
Abstract
Pharmacokinetic/pharmacodynamic (PKPD) modelling is used to describe and quantify dose-concentration-effect relationships. Within paediatric studies in infectious diseases and immunology these methods are often applied to developing guidance on appropriate dosing. In this paper, an introduction to the field of PKPD modelling is given, followed by a review of the PKPD studies that have been undertaken in paediatric infectious diseases and immunology. The main focus is on identifying the methodological approaches used to define the PKPD relationship in these studies. The major findings were that most studies of infectious diseases have developed a PK model and then used simulations to define a dose recommendation based on a pre-defined PD target, which may have been defined in adults or in vitro. For immunological studies much of the modelling has focused on either PK or PD, and since multiple drugs are usually used, delineating the relative contributions of each is challenging. The use of dynamical modelling of in vitro antibacterial studies, and paediatric HIV mechanistic PD models linked with the PK of all drugs, are emerging methods that should enhance PKPD-based recommendations in the future.
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Affiliation(s)
- Charlotte I S Barker
- Paediatric Infectious Diseases Research Group, Division of Clinical Sciences, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK; Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK
| | - Eva Germovsek
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK
| | - Rollo L Hoare
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK; CoMPLEX, University College London, Physics Building, Gower Street, London WC1E 6BT, UK
| | - Jodi M Lestner
- Paediatric Infectious Diseases Research Group, Division of Clinical Sciences, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Joanna Lewis
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK; CoMPLEX, University College London, Physics Building, Gower Street, London WC1E 6BT, UK
| | - Joseph F Standing
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK; CoMPLEX, University College London, Physics Building, Gower Street, London WC1E 6BT, UK.
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17
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Rettinger E, Bonig H, Wehner S, Lucchini G, Willasch A, Jarisch A, Soerensen J, Esser R, Rossig C, Klingebiel T, Bader P. Feasibility of IL-15-activated cytokine-induced killer cell infusions after haploidentical stem cell transplantation. Bone Marrow Transplant 2013; 48:1141-3. [DOI: 10.1038/bmt.2013.19] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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18
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Borchers S, Bremm M, Lehrnbecher T, Dammann E, Pabst B, Wölk B, Esser R, Yildiz M, Eder M, Stadler M, Bader P, Martin H, Jarisch A, Schneider G, Klingebiel T, Ganser A, Weissinger EM, Koehl U. Sequential anti-cytomegalovirus response monitoring may allow prediction of cytomegalovirus reactivation after allogeneic stem cell transplantation. PLoS One 2012; 7:e50248. [PMID: 23272059 PMCID: PMC3521740 DOI: 10.1371/journal.pone.0050248] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 10/19/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Reconstitution of cytomegalovirus-specific CD3(+)CD8(+) T cells (CMV-CTLs) after allogeneic hematopoietic stem cell transplantation (HSCT) is necessary to bring cytomegalovirus (CMV) reactivation under control. However, the parameters determining protective CMV-CTL reconstitution remain unclear to date. DESIGN AND METHODS In a prospective tri-center study, CMV-CTL reconstitution was analyzed in the peripheral blood from 278 patients during the year following HSCT using 7 commercially available tetrameric HLA-CMV epitope complexes. All patients included could be monitored with at least CMV-specific tetramer. RESULTS CMV-CTL reconstitution was detected in 198 patients (71%) after allogeneic HSCT. Most importantly, reconstitution with 1 CMV-CTL per µl blood between day +50 and day +75 post-HSCT discriminated between patients with and without CMV reactivation in the R+/D+ patient group, independent of the CMV-epitope recognized. In addition, CMV-CTLs expanded more daramtaically in patients experiencing only one CMV-reactivation than those without or those with multiple CMV reactivations. Monitoring using at least 2 tetramers was possible in 63% (n = 176) of the patients. The combinations of particular HLA molecules influenced the numbers of CMV-CTLs detected. The highest CMV-CTL count obtained for an individual tetramer also changed over time in 11% of these patients (n = 19) resulting in higher levels of HLA-B*0801 (IE-1) recognizing CMV-CTLs in 14 patients. CONCLUSIONS Our results indicate that 1 CMV-CTL per µl blood between day +50 to +75 marks the beginning of an immune response against CMV in the R+/D+ group. Detection of CMV-CTL expansion thereafter indicates successful resolution of the CMV reactivation. Thus, sequential monitoring of CMV-CTL reconstitution can be used to predict patients at risk for recurrent CMV reactivation.
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Affiliation(s)
- Sylvia Borchers
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Melanie Bremm
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Thomas Lehrnbecher
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Elke Dammann
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Brigitte Pabst
- Institute of Human Genetics, Hannover Medical School, Hannover, Germany
| | - Benno Wölk
- Institute of Virology, Hannover Medical School, Hannover, Germany
| | - Ruth Esser
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Meral Yildiz
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
- Internal Medicine II, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Stadler
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Peter Bader
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Hans Martin
- Internal Medicine II, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Andrea Jarisch
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Gisbert Schneider
- Institute of Pharmaceutical Science and Biostatistics, ETH Zürich, Switzerland
| | - Thomas Klingebiel
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Eva M. Weissinger
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Ulrike Koehl
- Pediatric Hematology and Oncology, Johann Wolfgang Goethe-University, Frankfurt, Germany
- Institute of Cellular Therapeutics, IFB-Tx, Hannover Medical School, Hannover, Germany
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19
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Bartelink IH, Belitser SV, Knibbe CAJ, Danhof M, de Pagter AJ, Egberts TCG, Boelens JJ. Immune reconstitution kinetics as an early predictor for mortality using various hematopoietic stem cell sources in children. Biol Blood Marrow Transplant 2012; 19:305-13. [PMID: 23092812 DOI: 10.1016/j.bbmt.2012.10.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 10/10/2012] [Indexed: 11/15/2022]
Abstract
The severity of complications of allogeneic hematopoietic stem cell transplantation (HSCT) is governed mainly by the status of immune reconstitution. In this study, we investigated differences in immune reconstitution with different cell sources and the association between the kinetics of immune reconstitution and mortality. Immunophenotyping was performed every 2 weeks in children who had undergone HSCT between 2004 and 2008 at University Medical Center Utrecht. Lymphocyte reconstitution in the first 90 days after HSCT was studied in relation to mortality in 3 HSCT groups: matched sibling bone marrow (BM) recipients (35 patients), unrelated BM recipients (32 patients), and unrelated cord blood recipients (36 patients). The median age of recipients was 5.9 years (range, 0.1-21 years). The nature and speed of T cell, B cell, and natural killer (NK) cell reconstitution were highly dependent on the cell source. In the first 90 days after HSCT, faster B cell and NK cell reconstitution and delayed T cell reconstitution were shown in unrelated cord blood recipients compared with matched sibling BM and unrelated BM recipients. Of the lymphocyte subsets investigated, a large number of NK cells and a more rapid CD4(+) immune reconstitution over time, resulting in sustained higher CD4(+) counts, were the only predictors of a lower mortality risk in all cell sources. The final model showed that during the first 90 days, patients with an area under the CD4(+) cell receiver- operating curve of >4,300 cells/day and no peak in CD4(+) cell counts had the highest likelihood of survival (hazard ratio for mortality, 0.2; 95% confidence interval, 0.06-0.5). Our data indicate that CD4(+) kinetics may be used to identify patients at greatest risk for mortality early after HSCT.
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20
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Advanced flowcytometric analysis of regulatory T cells: CD127 downregulation early post stem cell transplantation and altered Treg/CD3+CD4+-ratio in severe GvHD or relapse. J Immunol Methods 2011; 373:36-44. [DOI: 10.1016/j.jim.2011.07.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 12/20/2022]
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21
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Rénard C, Barlogis V, Mialou V, Galambrun C, Bernoux D, Goutagny MP, Glasman L, Loundou AD, Poitevin-Later F, Dignat-George F, Dubois V, Picard C, Chabannon C, Bertrand Y, Michel G. Lymphocyte subset reconstitution after unrelated cord blood or bone marrow transplantation in children. Br J Haematol 2010; 152:322-30. [PMID: 21133884 DOI: 10.1111/j.1365-2141.2010.08409.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report the post-transplant lymphocyte subset recovery of 226 children treated with Unrelated Cord Blood transplant (UCBT) (n = 112) or Unrelated Bone Marrow Transplant (UBMT) (n = 114) for malignant or non-malignant diseases. Absolute numbers of natural killer (NK), B and T cells were monitored by flow cytometry up to 5 years post-transplant. Immunological endpoints were: time to achieve a CD3(+) cell count > 0·5 and 1·5 × 10⁹/l, CD4(+) > 0·2 and 0·5 × 10⁹/l, CD8(+) > 0·25 ×10⁹/l, CD19(+) > 0·2 × 10⁹/l, NK > 0·1 × 10⁹/l. These endpoints were analysed through the use of cumulative incidence curves in the context of competing risks. CD8(+) T cell recovery was delayed after UCBT with a median time to reach CD8(+) T cells > 0·25 × 10⁹/l of 7·7 months whereas it was 2·8 months in UBMT (P < 0·001). B cell recovery was better in UCBT, with a median time to reach CD19(+) cells > 0·2 × 10⁹/l of 3·2 months in UCBT and 6·4 months in UBMT (P = 0·03). Median time for CD4(+) T cell and NK cell recovery was similar in UCBT and UBMT. CD4(+) T cells recovery was negatively correlated to age (better reconstitution in younger patients, P = 0·002). CD8(+) T cells recovery was shorter in recipients with a positive cytomegalovirus serology (P =0·001).
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Affiliation(s)
- Cécile Rénard
- Institut d'Hématologie et d'Oncologie Pédiatrique, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, France.
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