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Acute GVHD, BK hemorrhagic cystitis and age are risk factors for transplant-associated thrombotic microangiopathy in adults. Blood Adv 2021; 6:1342-1349. [PMID: 34932790 PMCID: PMC8864665 DOI: 10.1182/bloodadvances.2021004933] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 11/18/2021] [Indexed: 11/30/2022] Open
Abstract
Clinically actionable thrombotic microangiopathy (CA-TMA) occurring in the absence of aGVHD occurs earlier than day 100. aGVHD is a key and consistent risk factor for late-onset CA-TMA.
Hematopoietic cell transplantation–associated thrombotic microangiopathy (TMA) is a complication associated with higher nonrelapse mortality (NRM) in patients who undergo allogeneic transplant (HCT). Current classification criteria are not generally agreed on or validated, and the presence of confounding factors after transplant contribute to underdiagnosis or delayed diagnosis of TMA. We studied risk factors, incidence, and biomarkers of TMA in 119 adult allogeneic HCT recipients. Twenty-seven patients developed a clinically actionable phenotype of TMA (CA-TMA) and the incidence of CA-TMA was 22% by day 180. Among the 27 patients who developed CA-TMA, 10 developed it before the onset of acute graft-versus-host disease (aGVHD), and 17 patients developed it after the onset of aGVHD. We report for the first time that age >50 years, BK hemorrhagic cystitis, and other viral infections (CMV, HHV-6, or adenovirus) are risk factors for adult CA-TMA. Even after adjustment for aGVHD, CA-TMA was independently associated with significantly higher NRM. These data illustrate relationships between CA-TMA and aGVHD, describe new risk factors for CA-TMA and emphasizes the need to develop validated set of criteria for timely diagnosis.
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3
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Complement-mediated thrombotic microangiopathy as a link between endothelial damage and steroid-refractory GVHD. Blood Adv 2019; 2:2619-2628. [PMID: 30327370 DOI: 10.1182/bloodadvances.2018020321] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/07/2018] [Indexed: 12/19/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA), a complication of hematopoietic cell transplant (HCT), is associated with significant morbidity and mortality. The pathophysiology and overlap of TA-TMA with other posttransplant complications such as graft-versus-host disease (GVHD) is poorly understood. We retrospectively identified cases of TA-TMA among patients with grade 3/4 gastrointestinal (GI) GVHD, reviewed intestinal biopsy specimens, and performed correlative testing of biomarkers associated with TA-TMA. TA-TMA was more common in patients with steroid-refractory GVHD compared with steroid-responsive GVHD (79.3% vs 42.1%; P = .001). Among patients surviving 100 days post-HCT, 1-year survival from day 100 was significantly better for patients who had not developed TA-TMA in the first 100 days (69.5% vs 36.7%; P < .001). Only 1 of 7 proposed TA-TMA histology criteria (mucosal hemorrhage) differed significantly based on GVHD steroid response. In multivariable modeling, steroid-refractory GVHD was a risk factor for development of TA-TMA (hazard ratio, 3.09; 95% confidence interval, 1.68-5.67; P < .001). There were no differences in complement activation at GVHD onset; however, 2 to 6 weeks later, patients with TA-TMA had higher levels of BBPlus and C5b-9, markers of alternative and terminal pathway activation (BBPlus: median, 600 vs 209.3 ng/mL; P = .0045) (C5b-9: median, 425.9 vs 258.4 ng/mL; P = .029). TA-TMA is associated with poor overall survival (OS) following HCT and may be detected early by histologic findings and may be differentiated from GVHD by measurement of alternative and terminal complement pathway activation. It is unknown whether treatment of TA-TMA will improve survival in steroid-refractory GVHD.
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Zhao XS, Huang XJ. Seeking biomarkers for acute graft-versus-host disease: where we are and where we are heading? Biomark Res 2019; 7:17. [PMID: 31406575 PMCID: PMC6685226 DOI: 10.1186/s40364-019-0167-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/10/2019] [Indexed: 12/16/2022] Open
Abstract
Acute graft-versus-host disease (aGVHD) is one of the most important complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT), which would seriously affect the clinical outcomes of patients. Early diagnosis and early intervention are keys for improving its curative efficacy. Thus, seeking the biomarkers of aGVHD that can accurately identify and diagnose aGVHD is very important to guiding the intervention and treatment of aGVHD. For the past decades, many studies have focused on searching for aGVHD-related biological markers to assist in diagnosis, early warning, and risk stratification. Unfortunately, until now, no reliable aGVHD biomarker is available that is recognized and widely used in clinical practice. With the continuous development of biological technology, as well as our in-depth understanding of the pathophysiologic mechanism of aGVHD, the selection, examination and application of biological markers have changed much. In this review, we summarized the progress of aGVHD biological marker screening, identification, preliminary clinical application, and look forward to a promising development direction in the future.
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Affiliation(s)
- Xiao-Su Zhao
- 1Peking University Peopl's Hospital, Peking University Institute of Hematology, No.11 Xizhimen South Street, Beijing, 100044 China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,3Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- 1Peking University Peopl's Hospital, Peking University Institute of Hematology, No.11 Xizhimen South Street, Beijing, 100044 China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,3Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,4Peking-Tsinghua Center for Life Sciences, Beijing, China
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5
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Kellner JN, Delemarre EM, Yvon E, Nierkens S, Boelens JJ, McNiece I, Olson A, Nieto Y, Ciurea S, Popat U, Ahmed S, Champlin R, Ramos J, Nishimoto M, Ma H, Ke Z, Thall P, Khoury JD, Negrin R, Andersson B, Parmar S. Third party, umbilical cord blood derived regulatory T-cells for prevention of graft versus host disease in allogeneic hematopoietic stem cell transplantation: feasibility, safety and immune reconstitution. Oncotarget 2018; 9:35611-35622. [PMID: 30479692 PMCID: PMC6235025 DOI: 10.18632/oncotarget.26242] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 10/06/2018] [Indexed: 12/14/2022] Open
Abstract
Incubation of umbilical cord blood (UCB) derived regulatory T-cells (Tregs) with fucosyltransferase enzyme improves their ability to home to the target tissue to prevent graft vs. host disease (GVHD). We report results of 5 patients (Double UCB Transplant, n=2; Peripheral Blood Matched Unrelated Donor Transplant, n=3) who received UCB-Tregs (Dose level = 1×106/kg), infused one day prior to the donor graft. All patients received their designated UCB-Treg dose without any infusion reaction. The ratio of conventional T-cells in donor graft was at least 10 times higher than infused UCB-Tregs (ratio range, 12-356). All patients engrafted at median of 13 days (range, 8-17 days). One patient died due to brain hemorrhage on day 45. A bi-modal increase of plasma IL-10 level occurred on day 7 and day 21 and notably, plasma IL-2 level dropped significantly in all patients at Day 7. All evaluable patients developed ≥grade II acute GVHD and at 1 year follow up, all were alive and without evidence of disease relapse. No increase in the chronic GVHD biomarkers (REG3a and Elafin) was observed at day 7. At the time of last follow up, all evaluable patients were off immune-suppression. Stage 2 of this clinical trial examining UCB-Treg at dose level= 1×107/kg is currently underway.
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Affiliation(s)
- Joshua N Kellner
- Department of Experimental Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eveline M Delemarre
- Laboratory of Translational Immunology, University Medical Center Utrecht, Heidelberglaan, CX Utrecht, The Netherlands
| | - Eric Yvon
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefan Nierkens
- Laboratory of Translational Immunology, University Medical Center Utrecht, Heidelberglaan, CX Utrecht, The Netherlands
| | - Jaap J Boelens
- Department of Pediatrics, Stem Cell Transplant and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ian McNiece
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yago Nieto
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefan Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sairah Ahmed
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer Ramos
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mitsutaka Nishimoto
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hongbing Ma
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeng Ke
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Thall
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Robert Negrin
- Division of Blood and Marrow Transplantation, Stanford University, Palo Alto, CA, USA
| | - Borje Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Simrit Parmar
- Department of Experimental Therapeutics, University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Köninger A, Kampmeier A, Mach P, Schmidt B, Strowitzki T, Kimmig R, Gellhaus A. Tight interplay in early pregnancy between follistatin and anti-mullerian hormone in women with polycystic ovarian syndrome (PCOS). Arch Gynecol Obstet 2018; 297:1307-1316. [PMID: 29453653 DOI: 10.1007/s00404-018-4718-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 02/09/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE Follistatin levels increase during the course of pregnancy and may play a role in ovarian arrest, reflected by the simultaneous decrease of anti-mullerian-hormone (AMH) levels. The aim of the study was to investigate AMH and follistatin levels during the hormonal window at the beginning of pregnancy. Since both parameters are described as deregulated in polycystic ovarian syndrome (PCOS), subgroup analysis of PCOS patients may additionally elucidate their interplay and effects on ovarian activity. METHODS Serum samples were retrospectively analyzed using the AMH Gen II ELISA and the Human Follistatin Quantikine ELISA Kit. Samples were collected longitudinally from 57 patients (32 with PCOS and 25 controls) before conception and during the first trimester. In 18 patients, measurements from the early and the late first trimester were available. Potential associations of AMH and follistatin levels with PCOS-related parameters were compared between the subgroups as well as longitudinally before and in the first trimester of pregnancy. For statistical analysis, the Spearman's correlation, Wilcoxon test, t test, Friedman test and multiple linear regression analysis was performed. RESULTS In contrast to AMH, follistatin levels differed not between controls and PCOS patients before and in pregnancy. In both subgroups, AMH levels significantly decreased and follistatin levels significantly increased in longitudinally performed measurements before conceiving and in the first trimester of pregnancy. CONCLUSION Follistatin levels are not suited as a biomarker for PCOS, but could be involved in suppressing ovarian activity, as reflected by AMH levels at the beginning of pregnancy.
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Affiliation(s)
- Angela Köninger
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany.
| | - Antje Kampmeier
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Pawel Mach
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Boerge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Thomas Strowitzki
- Department of Gynecological Endocrinology and Reproductive Medicine, University of Heidelberg, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Alexandra Gellhaus
- Department of Gynecology and Obstetrics, University of Duisburg-Essen, Hufelandstrasse 55, 45122, Essen, Germany
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