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Outcomes of allogeneic haematopoietic stem cell transplantation for patients with severe aplastic anaemia using the porcine antilymphocyte globulin-containing conditioning regimen. Ann Hematol 2020; 99:1863-1871. [PMID: 32556453 DOI: 10.1007/s00277-020-04111-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 06/01/2020] [Indexed: 10/24/2022]
Abstract
Antithymocyte globulin (ATG) is widely used for allogeneic haematopoietic stem cell transplantation (allo-HSCT) in severe aplastic anaemia (SAA). Only rabbit-ATG (r-ATG) and porcine-antilymphocyte globulin (p-ALG) are available in China, but the p-ALG-containing conditioning regimen for allo-HSCT in SAA has seldom been reported. In this study, we retrospectively evaluated the outcomes of 41 SAA patients receiving allo-HSCT with a p-ALG-containing conditioning regimen in our transplantation centre. All patients engrafted, and no death during conditioning was observed. The actuarial 3-year overall survival (OS) rates were 95.1 ± 3.4%. The actuarial 3-year disease-free survival (DFS) rates were 85.0 ± 5.7%. Acute graft-versus-host disease (aGVHD) predicted inferior OS (p < 0.05). The interval from diagnosis to transplantation for more than 100 days predicted an inferior DFS rate (p < 0.05) and a higher graft rejection/poor graft function (GR/PGF) rate (p < 0.01). In conclusion, the p-ALG-containing regimen showed satisfactory effects and safety in allo-HSCT for SAA patients. P-ALG could be a potential alternative preparation for r-ATG in SAA allo-HSCT.
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Kim T, Choi Y, Lee JH, Park S, Ahn JS, Moon JH, Shin HJ, Lee WS, Kim D, Lee HS. Clinical impact of anti-thymocyte globulin on survival and graft-versus-host disease in patients undergoing human leukocyte antigen mismatched allogeneic stem cell transplantation. Korean J Intern Med 2020; 35:429-437. [PMID: 30616303 PMCID: PMC7061010 DOI: 10.3904/kjim.2018.317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/04/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND/AIMS Rabbit anti-thymocyte globulin (ATG) is usually incorporated in hematopoietic stem cell transplantation (HSCT) to reduce the incidence of graft-versus-host disease (GVHD). This study aimed to find optimal ATG doses in patients undergoing human leukocyte antigen (HLA)-mismatched allogeneic HSCT. METHODS We retrospectively collected medical records from 352 consecutive patients with acute myeloid leukemia (n = 214), acute lymphoblastic leukemia (n = 62), or myelodysplastic syndrome (n = 76) in eight centers of Korea between 2005 and 2015. All patients received busulfan-based conditioning without total body irradiation (TBI) and received stem cells from HLA-mismatched donors. RESULTS In the current study, 5-year overall survival rates of patients receiving low to medium doses of ATG (2.5 to 7.5 mg/kg) were higher than those receiving other doses of ATG (hazard ratio [HR], 0.528; 95% confidence interval [CI], 0.311 to 0.897; p = 0.018). The incidence rates of extensive chronic GVHD (ecGVHD) after administration of low to medium doses of ATG were lower than those after other doses of ATG (HR, 0.447; 95% CI, 0.224 ton 0.889; p = 0.022). CONCLUSION The low to medium doses of ATG may be associated with improving survival outcomes and reducing incidence of ecGVHD without enhancing the chances of relapse in patients with acute leukemia or myelodysplastic syndrome undergoing non-TBI-based HLA-mismatched allogeneic HSCT.
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Affiliation(s)
- Taeyun Kim
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Yunsuk Choi
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Silvia Park
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Sook Ahn
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Joon-Ho Moon
- Department of Hematology, Kyungpook National University Hospital, Daegu, Korea
| | - Ho-Jin Shin
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Won Sik Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Dajung Kim
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
| | - Ho Sup Lee
- Department of Internal Medicine, Kosin University Gospel Hospital, Busan, Korea
- Correspondence to Ho Sup Lee, M.D. Department of Internal Medicine, Kosin University Gospel Hospital, 262 Gamcheon-ro, Seo-gu, Busan 49267, Korea Tel: +82-51-990-5820 Fax: +82-51-990-5820 E-mail:
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Hilal T, Slone S, Peterson S, Bodine C, Gul Z. Cytomegalovirus reactivation is associated with a lower rate of early relapse in myeloid malignancies independent of in-vivo T cell depletion strategy. Leuk Res 2017; 57:37-44. [PMID: 28279876 DOI: 10.1016/j.leukres.2017.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 02/22/2017] [Accepted: 02/26/2017] [Indexed: 11/19/2022]
Abstract
The association between cytomegalovirus (CMV) reactivation and relapse risk has not been evaluated in relation to T cell depletion strategies. We evaluated 93 patients who underwent allogeneic hematopoietic stem cell transplantation (HSCT) and analyzed the association between T cell depletion strategies with the cumulative incidence of relapse and CMV reactivation. A total of 33% of patients who received ATG vs. 34% who received alemtuzumab developed CMV reactivation. The cumulative incidence of relapse was 3% at 1year and 20% at 3 years in patients with CMV reactivation vs. 30% at 1year and 38% at 3 years in patients without CMV reactivation (p=0.02). When analyzed separately, this effect persisted in the myeloid, but not the lymphoid group. There was a numerical trend towards increased non-relapse mortality (NRM) in patients with CMV reactivation, especially in the myeloid group. The choice of T cell depleting agent and the rate of CMV reactivation were not associated with different overall survival (OS) rates. These results suggest that the choice of T cell depletion strategy may have similar effects on rates of CMV reactivation, disease relapse, and survival. Further studies examining these variables in patients not exposed to in-vivo T cell depleting agents may be of interest.
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Affiliation(s)
- Talal Hilal
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States; Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, AZ, United States.
| | - Stacey Slone
- Biostatistics Shared Resource Facility, University of Kentucky Markey Cancer Center, Lexington, KY, United States
| | - Shawn Peterson
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Charles Bodine
- Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Zartash Gul
- Division of Hematology and Blood and Marrow Transplant, University of Kentucky Markey Cancer Center, Lexington, KY, United States; Division of Hematology, University of Cincinnati Cancer Center, Cincinnati, OH, United States
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4
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Atta EH, de Oliveira DCM, Bouzas LF, Nucci M, Abdelhay E. Less graft-versus-host disease after rabbit antithymocyte globulin conditioning in unrelated bone marrow transplantation for leukemia and myelodysplasia: comparison with matched related bone marrow transplantation. PLoS One 2014; 9:e107155. [PMID: 25188326 PMCID: PMC4154845 DOI: 10.1371/journal.pone.0107155] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/12/2014] [Indexed: 01/12/2023] Open
Abstract
One of the major drawbacks for unrelated donor (UD) bone marrow transplantation (BMT) is graft-versus-host disease (GVHD). Despite results from randomized trials, antithymocyte globulin (ATG) is not routinely included for GVHD prophylaxis in UD BMT by many centers. One of ways to demonstrate the usefulness of rabbit ATG in UD BMT is to evaluate how its results approximate to those observed in matched related (MRD) BMT. Therefore, we compared the outcomes between UD BMT with rabbit ATG (Thymoglobulin) for GVHD prophylaxis (n = 25) and MRD BMT (n = 91) for leukemia and myelodysplasia. All but one patient received a myeloablative conditioning regimen. Grades II–IV acute GVHD were similar (39.5% vs. 36%, p = 0.83); however, MRD BMT recipients developed more moderate-severe chronic GVHD (36.5% vs. 8.6%, p = 0.01) and GVHD-related deaths (32.5% vs. 5.6%, p = 0.04). UD BMT independently protected against chronic GVHD (hazard ratio 0.23, p = 0.04). The 6-month transplant-related mortality, 1-year relapse incidence, and 5-year survival rates were similar between patients with non-advanced disease in the MRD and UD BMT groups, 13.8% vs. 16.6% (p = 0.50), 20.8% vs. 16.6% (p = 0.37), and 57% vs. 50% (p = 0.67), respectively. Stable full donor chimerism was equally achieved (71.3% vs. 71.4%, p = 1). Incorporation of rabbit ATG in UD BMT promotes less GVHD, without jeopardizing chimerism evolution, and may attain similar survival outcomes as MRD BMT for leukemia and myelodysplasia especially in patients without advanced disease.
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Affiliation(s)
| | | | | | - Márcio Nucci
- University Hospital, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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5
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Mannoor K, Xu Y, Chen C. Natural autoantibodies and associated B cells in immunity and autoimmunity. Autoimmunity 2013. [DOI: 10.3109/08916934.2012.748753] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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6
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Bacigalupo A, Lamparelli T, Milone G, Sormani MP, Ciceri F, Peccatori J, Locasciulli A, Majolino I, Di Bartolomeo P, Mazza F, Sacchi N, Pollicheni S, Pinto V. Pre-emptive treatment of acute GVHD: a randomized multicenter trial of rabbit anti-thymocyte globulin, given on day+7 after alternative donor transplants. Bone Marrow Transplant 2009; 45:385-91. [DOI: 10.1038/bmt.2009.151] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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7
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Kröger N, Zabelina T, Binder T, Ayuk F, Bacher U, Amtsfeld G, Lellek H, Schrum J, Erttmann R, Eiermann T, Zander A. HLA-Mismatched Unrelated Donors as an Alternative Graft Source for Allogeneic Stem Cell Transplantation after Antithymocyte Globulin-Containing Conditioning Regimen. Biol Blood Marrow Transplant 2009; 15:454-62. [DOI: 10.1016/j.bbmt.2009.01.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2008] [Accepted: 01/06/2009] [Indexed: 11/29/2022]
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8
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Ayuk F, Zander A, Kröger N. Antitumor effects of polyclonal antithymocyte globulins: focus on B-cell malignancies and multiple myeloma. Ann Hematol 2009; 88:401-4. [DOI: 10.1007/s00277-009-0696-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2008] [Accepted: 01/08/2009] [Indexed: 11/29/2022]
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9
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Comparison of Two Doses of Antithymocyte Globulin in Patients Undergoing Matched Unrelated Donor Allogeneic Stem Cell Transplantation. Biol Blood Marrow Transplant 2008; 14:913-9. [DOI: 10.1016/j.bbmt.2008.05.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Accepted: 05/28/2008] [Indexed: 11/19/2022]
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10
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Ayuk F, Diyachenko G, Zabelina T, Panse J, Wolschke C, Eiermann T, Binder T, Fehse B, Erttmann R, Kabisch H. Anti-thymocyte globulin overcomes the negative impact of HLA mismatching in transplantation from unrelated donors. Exp Hematol 2008; 36:1047-54. [DOI: 10.1016/j.exphem.2008.03.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Revised: 01/31/2008] [Accepted: 03/03/2008] [Indexed: 10/22/2022]
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11
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Remberger M, Mattsson J, Hausenberger D, Schaffer M, Svahn BM, Ringdén O. Genomic tissue typing and optimal antithymocyte globuline dose using unrelated donors results in similar survival and relapse as HLA-identical siblings in haematopoietic stem-cell transplantation for leukaemia. Eur J Haematol 2008; 80:419-28. [DOI: 10.1111/j.1600-0609.2008.01047.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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12
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Anti-leukaemic role of acute GvHD after unrelated haematopoietic stem cell transplantation in intermediate- to high-risk acute myelogenous leukaemia. Bone Marrow Transplant 2007; 40:1069-74. [PMID: 17922041 DOI: 10.1038/sj.bmt.1705873] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Little is known about the role of acute GvHD (aGvHD) based on the concept of graft-versus-leukaemia effect (GVLE) after unrelated donor haematopoietic stem cell transplantation (uHSCT). We evaluated 67 uHSCTs performed with multinational unrelated donors for patients with AML. The median follow-up duration was 18 months (range 7-61). The majority of patients had intermediate- or high-risk cytogenetic findings. The conditioning regimen for most patients consisted of cyclophosphamide plus total body irradiation (n=56) with our standard GvHD prophylaxis containing tacrolimus plus a short course of methotrexate. The incidence of aGvHD and chronic GvHD was 50 and 52%, respectively. Eight patients (12%) have relapsed to date. The estimated overall disease-free survival (DFS) rate at 5 years was 67%. Notably fewer relapses were seen when aGvHD developed (P=0.008). Specifically, high-risk AML patients had a much lower relapse rate when they developed aGvHD (P=0.01), compared with the intermediate-risk group. Therefore, the development of aGvHD after uHSCT in AML patients is closely related to a lower relapse rate, probably in association with GVLE.
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Abstract
Acute graft-versus-host disease (GvHD) is a frequent complication of allogeneic haemopoietic stem cell transplantation (HSCT) and donor lymphocyte infusions (DLI). Its incidence and severity depends on several factors, such as prophylaxis method, donor/recipient matching, intensity of the conditioning regimen and composition of the graft. Significant progress has been made in recent years in understanding the pathogenesis of the disease, and some of these advances have been translated into clinical trials. First-line treatment of acute GvHD is based on corticosteroids, and produce sustained responses in 50-80% of patients depending on the initial severity. Non-responders are offered second-line therapy, with combinations of immunosuppressive agents, but 1-year survival is 30% in most large trials. New strategies explored include infusion of expanded mesenchymal stem cells (MSC), down regulation of antigen-presenting cells (APC) and suicide gene transduced T cells. Acute GvHD is complicated by severe immunodeficiency causing life-threatening infections. To date, GvHD has not been differentiated from the graft-versus-leukaemia effect. The present review will discuss some of these aspects.
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Affiliation(s)
- Andrea Bacigalupo
- Divisione Ematologia e Trapianto di Midollo, Ospedale San Martino, Genova, Italy.
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14
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Russell JA, Turner AR, Larratt L, Chaudhry A, Morris D, Brown C, Quinlan D, Stewart D. Adult Recipients of Matched Related Donor Blood Cell Transplants Given Myeloablative Regimens Including Pretransplant Antithymocyte Globulin Have Lower Mortality Related to Graft-versus-Host Disease: A Matched Pair Analysis. Biol Blood Marrow Transplant 2007; 13:299-306. [DOI: 10.1016/j.bbmt.2006.10.017] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Accepted: 10/12/2006] [Indexed: 12/01/2022]
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15
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Vassilev T, Mihaylova N, Voynova E, Nikolova M, Kazatchkine M, Kaveri S. IgM-enriched human intravenous immunoglobulin suppresses T lymphocyte functions in vitro and delays the activation of T lymphocytes in hu-SCID mice. Clin Exp Immunol 2006; 145:108-15. [PMID: 16792680 PMCID: PMC1942011 DOI: 10.1111/j.1365-2249.2006.03098.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Previous studies of an experimental human immunoglobulin preparation for intravenous use, containing normal pooled IgM (IVIgM), have shown its beneficial therapeutic effect in experimental autoimmune diseases. The mechanisms of its immunomodulatory activity remain however, poorly understood. In the experiments reported here, IVIgM inhibited the proliferation of various autonomously growing human lymphoid cell lines in vitro, as well as of MLR- and of PHA-stimulated human T-lymphocytes. These effects of IVIgM were observed at non-apoptotic concentrations and were stronger on a molar basis than those of normal pooled IgG for intravenous use (IVIg). Both preparations, when administered to SCID mice, repopulated with human peripheral blood mononuclear cells, delayed the expression of the early activation marker CD69 on both human CD4+ and CD8+ T-lymphocytes, activated by the mouse antigenic environment. The data obtained show that normal pooled human IgM exerts a powerful antiproliferative effect on T-cells that is qualitatively similar but quantitatively superior to that of therapeutic IVIg. Our results suggest that infusions with IVIgM might have a significant beneficial immunomodulating activity in patients with selected autoimmune diseases.
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Affiliation(s)
- T Vassilev
- Department of Immunology, Stefan Angeloff Institute of Microbiology, Bulgarian Academy of Sciences, Sofia, Bulgaria.
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16
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Bacigalupo A. Antilymphocyte/thymocyte globulin for graft versus host disease prophylaxis: efficacy and side effects. Bone Marrow Transplant 2005; 35:225-31. [PMID: 15558041 DOI: 10.1038/sj.bmt.1704758] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antilymphocyte/thymocyte globulins (ALGs/ATGs) have now been used for over 30 years in the setting of hemopoietic stem cell transplants (HSCT), with the aim of preventing graft-versus-host disease (GvHD). This is true especially for transplants from alternative donors. In this review, we will be discussing available published and unpublished data on the advantages and disadvantages of using ALG/ATG before or after an allogeneic HSCT. These studies show that ALG/ATG significantly reduce the incidence and severity of acute and chronic GvHD. Unfortunately, they also show that immune deficiency is a more prolonged and infectious complication more frequent in patients receiving ALG/ATG, suggesting the importance of aggressive monitoring of viral and fungal infections. In particular, the emerging problem of Epstein-Barr virus (EBV) infections and EBV-related lymphoproliferative disorders will be discussed, together with the use of pre-emptive therapy with rituximab. I personally believe ALG/ATG has an important role in allogeneic HSCT, especially today with the increasing use of peripheral blood transplants and the consequent high risk of chronic GvHD. ALG/ATG should be used with caution, and the negative consequences must be understood and possibly prevented.
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Affiliation(s)
- A Bacigalupo
- Dipartimento di Emato-Oncologia, Ospedale San Martino, Genova, Italy.
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17
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Basara N, Baurmann H, Kolbe K, Yaman A, Labopin M, Burchardt A, Huber C, Fauser AA, Schwerdtfeger R. Antithymocyte globulin for the prevention of graft-versus-host disease after unrelated hematopoietic stem cell transplantation for acute myeloid leukemia: results from the multicenter German cooperative study group. Bone Marrow Transplant 2005; 35:1011-8. [PMID: 15821768 DOI: 10.1038/sj.bmt.1704957] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A total of 155 patients with acute myeloid leukemia (AML) received hematopoietic stem cell transplants from unrelated donors after standard conditioning. Clinical outcome after the use of two different antithymocyte globulins for the prevention of graft-versus-host disease (GvHD) was analyzed in a retrospective study as follows: rabbit ATG (Thymoglobulin Sangstat/Genzyme, n=49, median age 42 years, 53% in CR, further ATG-S); rabbit ATG (ATG-Fresenius, n=38, median age 42 years, 58% in CR, further ATG-F) or no ATG (n=68, median age 36 years, 55% in CR). The groups were comparable regarding disease status at transplant, age, CMV status and cytogenetics. Grade III-IV acute GvHD was found in 15% in the ATG and 27% in the no ATG group (P=0.44). The most important independent risk factors for chronic GvHD (cGvHD) were the use of ATG, disease status at transplant and conditioning. cGvHD developed significantly more frequently in no ATG group. With the median follow-up of 34 months, the 5-year survival is 42% for those transplanted in CR. To conclude, these data demonstrate that the transplants performed in CR, with ATG, are associated with a good outcome, low incidence of cGvHD and no increase of relapse.
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Affiliation(s)
- N Basara
- Clinic for Bone Marrow Transplantation and Hematology/Oncology, Idar-Oberstein, Germany.
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Kang HJ, Shin HY, Choi HS, Ahn HS. Fludarabine, cyclophosphamide plus thymoglobulin conditioning regimen for unrelated bone marrow transplantation in severe aplastic anemia. Bone Marrow Transplant 2004; 34:939-43. [PMID: 15489866 DOI: 10.1038/sj.bmt.1704720] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Antithymocyte globulin (ATG) has been used in severe aplastic anemia (SAA) as a part of the conditioning regimen. Among the many kinds of ATG preparations, thymoglobulin had been found to be more effective in preventing GVHD and rejection of organ transplants. As the fludarabine-based conditioning regimens without total body irradiation have been reported to be promising for bone marrow transplantation (BMT) from alternative donors in SAA, thymoglobulin was added to fludarabine and cyclophosphamide conditioning to reduce GVHD and to allow good engraftment in unrelated BMT. Five patients underwent BMT with cyclophosphamide (50 mg/kg once daily i.v. on days -9, -8, -7 and -6), fludarabine (30 mg/m2 once daily i.v. on days -5, -4, -3 and -2) and thymoglobulin (2.5 mg/kg once daily i.v. on days -3, -2 and -1) from HLA-matched unrelated donors. Complete donor type hematologic recovery was achieved in all patients. No serious complication occurred during BMT. Only one patient developed grade I acute GVHD resolved spontaneously. Except for one who had rupture of hepatic adenoma 78 days after BMT, all the other four patients are still alive with median 566 days. Fludarabine, cyclophosphamide plus thymoglobulin conditioning allows for the promising results of good engraftment, tolerable toxicity and minimal GVHD.
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Affiliation(s)
- H J Kang
- Pediatric Oncology Branch, National Cancer Center, Gyeonggi-do, Republic of Korea
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Khoury H, Trinkaus K, Zhang MJ, Adkins D, Brown R, Vij R, Goodnough LT, Ma MK, McLeod HL, Shenoy S, Horowitz M, Dipersio JF. Hydroxychloroquine for the prevention of acute graft-versus-host disease after unrelated donor transplantation. Biol Blood Marrow Transplant 2004; 9:714-21. [PMID: 14652855 DOI: 10.1016/j.bbmt.2003.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hydroxychloroquine (HCQ) is an immunosuppressive agent that interferes with antigen presentation and with activity against graft-versus-host disease (GVHD). In a phase II trial assessing the GVHD prophylactic effects of HCQ, 51 consecutive unrelated donor transplant recipients received HCQ in addition to cyclosporin A, methylprednisolone, and methotrexate. HCQ was initiated on pretransplantation day -21 at 800 mg/d and continued until day +100 after transplantation. HCQ was extremely well tolerated and was not associated with side effects. Pharmacokinetic analyses demonstrated large inter- and intrapatient variability. The addition of HCQ did not affect posttransplantation immune recovery. Grade II to IV acute GVHD was observed in 56% of patients, and grade III and IV GVHD was observed in 17%. Day +100 mortality was 22%. When compared with a matched cohort of patients reported to the International Bone Marrow Transplant Registry, patients receiving HCQ had comparable cumulative incidences of grade II to IV acute GVHD. However, lower incidences of grades III and IV GVHD and better GVHD-free survival were observed in HCQ-treated patients (P =.01). We conclude that prophylactic HCQ is well tolerated and associated with a low incidence of severe acute GVHD. An ongoing placebo-controlled randomized trial will further determine what role HCQ plays in preventing GVHD after allografting.
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Affiliation(s)
- H Khoury
- Division of Oncology, Section of Leukemia & Bone Marrow, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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20
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Schetelig J, Bornhäuser M, Kiehl M, Schwerdtfeger R, Kröger N, Runde V, Zabelina T, Held TK, Thiede C, Fauser AA, Beelen D, Zander A, Ehninger G, Siegert W. Reduced-intensity conditioning with busulfan and fludarabine with or without antithymocyte globulin in HLA-identical sibling transplantation – a retrospective analysis. Bone Marrow Transplant 2003; 33:483-90. [PMID: 14716342 DOI: 10.1038/sj.bmt.1704384] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It is unknown whether the addition of antithymocyte globulin (ATG) to reduced-intensity conditioning with busulfan (BU) and fludarabine (FLU) is beneficial in HLA-identical sibling transplantation. Therefore, we analyzed retrospectively data on 83 patients, who received peripheral blood stem cells from HLA-identical siblings after conditioning with either 8 mg/kg BU and 150 mg/m2 FLU (n=45) or 8 mg/kg BU, 180 mg/m2 FLU and 40 mg/kg ATG (n=38). Graft-versus-host disease (GVHD) prophylaxis consisted of CSA alone (n=32) or a combination with either MTX or MMF (n=51). The median age was 52 years. Graft failure occurred in two patients after BU/FLU and in three after BU/FLU/ATG (P=0.66). After conditioning with BU/FLU, platelet recovery was significantly faster (P=0.017), and less platelet (P<0.001) and red blood cell (P=0.002) support was needed. Incidences of acute GVHD grades II and IV were 46 and 49%, respectively. Limited chronic GVHD occurred more often after BU/FLU compared to BU/FLU/ATG (54 vs 23%, P=0.02). The overall survival, non-relapse and relapse mortality did not differ significantly. We conclude that in peripheral blood stem cell transplantation from HLA-identical siblings after reduced-intensity conditioning with BU and FLU, ATG has no major impact on the rate of graft rejection and acute GVHD, but it reduces the incidence of limited chronic GVHD.
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Affiliation(s)
- J Schetelig
- Charité Campus Virchow Klinikum, Humboldt-Universität zu Berlin, Klinik für Innere Medizin mS Hämatologie und Onkologie, Berlin, Germany
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21
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Meijer E, Cornelissen JJ, Löwenberg B, Verdonck LF. Antithymocyteglobulin as prophylaxis of graft failure and graft-versus-host disease in recipients of partially T-cell-depleted grafts from matched unrelated donors: a dose-finding study. Exp Hematol 2003; 31:1026-30. [PMID: 14585365 DOI: 10.1016/s0301-472x(03)00204-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE In this study, we set out to evaluate the effect of three different antithymocyteglobulin (ATG) doses on graft failure and incidence of graft-vs-host disease (GVHD) among recipients of partially T-cell-depleted (TCD) grafts from matched unrelated donors (MUDs). PATIENTS AND METHODS Data of 74 consecutively treated MUD recipients were analyzed. Fifty-two, 13, and 9 MUD patients were treated with ATG in a total dose of 8 mg/kg, 6 mg/kg, and 4 mg/kg (given from days -8 until -4), respectively. RESULTS Granulocyte and platelet engraftment were not different between the groups, while graft failure was observed in two patients only (receiving 8 mg/kg and 4 mg/kg ATG, respectively). The cumulative incidence of severe (grade III-IV) acute GVHD and extensive chronic GVHD was 4%, 0%, 44% and 11%, 8%, 44% in groups receiving ATG in a dose of 8 mg/kg, 6 mg/kg, and 4 mg/kg, respectively (severe acute GVHD: p<0.001; extensive chronic GVHD: p=0.05). CONCLUSION Based on these findings, we recommend when ATG is used in the setting of stem cell transplantation with (partially) TCD grafts from MUDs, to give a total dose of 6 to 8 mg/kg. A further decrease in dosage resulted in a highly significant increased incidence of severe acute and extensive chronic GVHD.
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Affiliation(s)
- Ellen Meijer
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands.
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22
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Zander AR, Kröger N, Schleuning M, Finke J, Zabelina T, Beelen D, Schwerdtfeger R, Baurmann H, Bornhäuser M, Ehninger G, Fauser AA, Kiehl M, Trenschel R, Ottinger HD, Bertz H, Berger J, Kolb HJ, Schaefer UW. ATG as part of the conditioning regimen reduces transplant-related mortality (TRM) and improves overall survival after unrelated stem cell transplantation in patients with chronic myelogenous leukemia (CML). Bone Marrow Transplant 2003; 32:355-61. [PMID: 12900771 DOI: 10.1038/sj.bmt.1704157] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Matched unrelated donor transplants have an increased risk of severe graft-versus-host disease and transplant-related mortality (TRM). ATG has been introduced to decrease GvHD and to facilitate engraftment. We conducted a retrospective analysis of 333 patients with chronic myelogenous leukemia, who were treated with Fresenius ATG (n=145, average=90 mg/kg bw, range 40-90 mg/kg bw) or standard immunosuppression without ATG (n=188). Both groups were comparable regarding distribution of age, sex, HLA-matched vs mismatched donors. ATG Fresenius led to a faster leukocyte engraftment, decreased the incidence of acute GvHD and TRM (P=0.01 and P=0.03) and led to a significant better overall survival (70 vs 57%, P=0.03). We concluded that a prospective randomized study is needed to evaluate the definite role of ATG in hemopoietic stem cell transplantation.
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Affiliation(s)
- A R Zander
- Department of Bone Marrow Transplantation, University Hospital Hamburg-Eppendorf, Germany
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23
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Bonifazi F, Bandini G, Rondelli D, Falcioni S, Stanzani M, Bontadini A, Tazzari PL, Arpinati M, Giannini B, Conte R, Baccarani M. Reduced incidence of GVHD without increase in relapse with low-dose rabbit ATG in the preparative regimen for unrelated bone marrow transplants in CML. Bone Marrow Transplant 2003; 32:237-42. [PMID: 12858193 DOI: 10.1038/sj.bmt.1704138] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
SUMMARY Antithymocyte globulin (ATG) treatment prevents graft failure and results in a low incidence of GVHD, but an increased risk of relapse could be expected as a consequence of reduced GVHD. From September 1995 to June 2001, 28 consecutive chronic myeloid leukemia (CML) patients underwent unrelated bone marrow transplants: 21 were in chronic phase (CP) and seven in advanced phase (AP). Median age was 35.5 years (range 20-50). HLA typing was based on high-resolution molecular techniques; in eight cases there were one or more allele mismatches. The preparative regimen consisted of TBI, EDX 120 mg/kg and rabbit ATG 15 mg/kg. All patients engrafted and no rejection occurred. Acute GVHD grade III-IV occurred in six patients (21%). Chronic GVHD occurred in 10 (40%) and it was extensive in one. Four out of seven patients transplanted in AP had a hematological relapse. Of 21 in CP, there was one cytogenetic and one molecular relapse: these two patients are now in complete remission with imatinib mesylate. With a median follow-up of 45.7 months, the 5-year survival is 76.2% for those transplanted in CP. These data demonstrate that transplants performed in CP, with low-dose ATG, are associated with a good outcome, low incidence of GVHD and no increase of relapse.
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Affiliation(s)
- F Bonifazi
- Institute of Hematology and Clinical Oncology L e A. Seràgnoli, University of Bologna, St Orsola Hospital, Bologna, Italy
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24
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Kröger N, Einsele H, Wolff D, Casper J, Freund M, Derigs G, Wandt H, Schäfer-Eckart K, Wittkowsky G, Schmitz N, Krüger W, Zabelina T, Renges H, Ayuk F, Krüll A, Zander A. Myeloablative intensified conditioning regimen with in vivo T-cell depletion (ATG) followed by allografting in patients with advanced multiple myeloma. A phase I/II study of the German Study-group Multiple Myeloma (DSMM). Bone Marrow Transplant 2003; 31:973-9. [PMID: 12774047 DOI: 10.1038/sj.bmt.1704049] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We investigated toxicity and efficacy of in vivo T-cell depletion with anti-thymocyte globulin (ATG) as part of an intensified myeloablative conditioning regimen followed by allogeneic stem cell transplantation in patients with advanced multiple myeloma. The conditioning regimen consisted of modified total body irradiation, busulfan and cyclophosphamide (n=15) or in the case of prior dose-limiting radiotherapy of busulfan and cyclophosphamide (n=3). The median age was 44 years (range, 29-53) and the median time from diagnosis to transplant was 12 months (range, 6-144). Grade II-IV acute graft-versus-host disease (GvHD) occurred in six patients (35%). Severe grade III/IV GvHD developed in one patient (6%). Three patients died of therapy-related causes (17%). A complete remission (CR) with negative immunofixation after allogeneic transplantation was seen in eight of the evaluable patients (53%). After a median follow-up of 41 months (range, 8-84), the estimated overall survival at 6 years for all patients is 77% (CI 95%: 58-96%). The estimated progression-free survival at 6 years for all patients is 31% (CI 95%: 2-59%) and 46% (CI 95%: 9-83%) for patients with CR. In vivo T-cell depletion with ATG resulted in a low rate of severe GvHD with low treatment-related mortality, and a substantial number of long-term survivors.
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Affiliation(s)
- Nicolaus Kröger
- Bone Marrow Transplantation, University Hospital Hamburg-Eppendorf, Germany
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25
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Weber M, Kröger N, Langer F, Hansen A, Zabelina T, Eifrig B, Hossfeld DK, Zander AR. Non-overt disseminated intravascular coagulation in patients during treatment with antithymocyte globulin for unrelated allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2003; 31:817-22. [PMID: 12732891 DOI: 10.1038/sj.bmt.1703921] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We assessed the effect of rabbit antithymocyte globulin manufactured by Fresenius (ATG-F) on the hemostatic system in patients (n=12) with various hematological malignancies undergoing hematopoietic stem cell transplantation (HSCT) from HLA-matched unrelated donors. For this purpose, we monitored different parameters of coagulation before, during and after the administration of ATG-F. As a control group, we recruited patients (n=10) undergoing HSCT from their HLA-identical siblings who did not receive ATG-F as part of their preparative regimens. At 24 and 48 h after ATG-F treatment had been initiated, we found a temporary rise in D-Dimer, tissue factor, soluble thrombomodulin and thrombin-antithrombin III complex levels and a significant decrease of platelet counts in patients treated with ATG-F as compared to the control group. No differences between the two groups could be detected with regard to global coagulation tests as well as the incidence of bleeding manifestations, thromboembolic complications or the development of vascular-occlusive-disease of the liver. This temporary state of a stressed but compensated coagulation system under ATG-F therapy can be addressed as nonovert disseminated intravascular coagulation (DIC). The effect was independent from the different conditioning regimens and eased off after cessation of ATG-F. We conclude that ATG-F can induce nonovert DIC in patients receiving antithymocyte globulin as part of their conditioning regimen for HSCT.
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Affiliation(s)
- M Weber
- Department of Internal Medicine II and Bone Marrow Transplantation Unit, University Hospital Hamburg-Eppendorf, Martinistrasse 52, Germany
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26
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Fehse N, Fehse B, Kröger N, Zabelina T, Freiberger P, Krüger W, Kabisch H, Erttmann R, Zander AR. Influence of anti-thymocyte globulin as part of the conditioning regimen on immune reconstitution following matched related bone marrow transplantation. JOURNAL OF HEMATOTHERAPY & STEM CELL RESEARCH 2003; 12:237-42. [PMID: 12804182 DOI: 10.1089/152581603321628377] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this work was to analyze the influence of anti-thymocyte globulin (ATG) as part of the conditioning regimen on immune reconstitution following matched related bone marrow transplantation. The rate and pattern of the recovery of total lymphocytes, natural killer (NK) cells, and several T and B cell subsets were determined in 38 patients for more than 2 years following BMT. We compared two patient groups: the first comprised 19 patients after matched related BMT without ATG prevention for graft-versus-host disease (GVHD) and the second contained 19 patients after matched related BMT with ATG treatment for GVHD prophylaxis. We observed impaired immune reconstitution in the ATG group in comparison with the non-ATG group, indicating a significant influence of ATG on immune recovery for several months after BMT.
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Affiliation(s)
- Natalja Fehse
- Bone Marrow Transplantation, University Hospital Eppendorf, Hamburg, Germany.
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27
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Nilsson C, Aschan J, Hentschke P, Ringdén O, Ljungman P, Hassan M. The effect of metronidazole on busulfan pharmacokinetics in patients undergoing hematopoietic stem cell transplantation. Bone Marrow Transplant 2003; 31:429-35. [PMID: 12665836 DOI: 10.1038/sj.bmt.1703896] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Busulfan (Bu) is an important component of some myeloablative regimens prior to stem cell transplantation (SCT). Over the last few years it has been shown that other drugs administered concomitantly can influence Bu pharmacokinetics. In the present study, we compared Bu concentrations (trough levels) in three groups of patients. Group A (n=5) received metronidazole as graft-versus-host disease prophylaxis during Bu treatment. Group B (n=9) received Bu only for 2 days followed by 2 days of Bu and metronidazole. Group C (n=10) was a control group that received Bu without metronidazole. The mean Bu levels for Group A receiving metronidazole during conditioning was significantly (P<0.001) higher (948+/-280 ng/ml), compared to those observed in the control group (507+/-75 ng/ml). In Group B, the administration of metronidazole resulted in a significant (P<0.001) increase in Bu levels (807+/-90 ng/ml) during the last 2 days, compared to 452+/-68 ng/ml during the first 2 days. In Group A, one patient died with multiorgan failure, three experienced veno-occlusive disease (VOD) and one developed hemorrhagic cystitis. Elevated liver transaminases (AST, ALT) and bilirubin were detected in all Group A patients. In Group B, six patients had elevated liver function tests but no VOD was observed. We conclude that metronidazole should not be administered simultaneously with Bu to avoid the high plasma levels of Bu, which may lead to severe toxicity and/or treatment related mortality.
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Affiliation(s)
- C Nilsson
- Department of Medicine, Huddinge University Hospital, Stockholm, Sweden
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28
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Kröger N, Sayer HG, Schwerdtfeger R, Kiehl M, Nagler A, Renges H, Zabelina T, Fehse B, Ayuk F, Wittkowsky G, Schmitz N, Zander AR. Unrelated stem cell transplantation in multiple myeloma after a reduced-intensity conditioning with pretransplantation antithymocyte globulin is highly effective with low transplantation-related mortality. Blood 2002; 100:3919-24. [PMID: 12393448 DOI: 10.1182/blood-2002-04-1150] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We investigated the feasibility of unrelated stem cell transplantation in 21 patients with advanced stage II/III multiple myeloma after a reduced-intensity conditioning regimen consisting of fludarabine (150 mg/m(2)), melphalan (100-140 mg/m(2)), and antithymocyte globulin (ATG; 10 mg/kg on 3 days). The median patient age was 50 years (range, 32-61 years). All patients had received at least one prior autologous transplantation, in 9 cases as part of an autologous-allogeneic tandem protocol. No graft failure was observed. At day 40 complete donor chimerism was detected in all patients. Grade II to IV acute graft-versus-host disease (GVHD) was seen in 8 patients (38%), and severe grade III/IV GVHD was observed in 4 patients (19%). Six patients (37%) developed chronic GVHD, but only 2 patients (12%) experienced extensive chronic GVHD. The estimated probability of nonrelapse mortality at day 100 was 10% and at 1 year was 26%. After allografting, 40% of the patients achieved a complete remission, and 50% achieved a partial remission, resulting in an overall response rate of 90%. After a median follow-up of 13 months, the 2-year estimated overall and progression-free survival rates are 74% (95% CI, 54%-94%) and 53% (95% CI, 29%-87%), respectively. A shorter progression-free survival was seen in patients who already experienced relapse to prior autograft (26% versus 86%, P =.04). Dose-reduced conditioning with pretransplantation ATG followed by unrelated stem cell transplantation provides durable engraftment and donor chimerism, reduces substantially the risk of transplant-related organ toxicity, and induces high remission rates.
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Affiliation(s)
- Nicolaus Kröger
- Department of Bone Marrow Transplantation, University Hospital Hamburg-Eppendorf, Germany.
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29
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Hessling J, Kröger N, Werner M, Zabelina T, Hansen A, Kordes U, Ayuk FA, Renges H, Panse J, Erttmann R, Zander AR. Dose-reduced conditioning regimen followed by allogeneic stem cell transplantation in patients with myelofibrosis with myeloid metaplasia. Br J Haematol 2002; 119:769-72. [PMID: 12437657 DOI: 10.1046/j.1365-2141.2002.03884.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Three patients with myelofibrosis received allogeneic stem cell transplantation after a dose-reduced conditioning regimen of busulphan (8 mg/kg), fludarabine (180 mg/m2) and antithymocyte globulin (4 x 10 mg/kg). The median age at transplantation was 51 years (range 44-58). All patients engrafted with a leucocyte count > 1.0 x 10(9)/l after a median of 18 d (range 16-20). Grade II acute skin graft-versus-host disease (GvHD) occurred in one patient. One limited and one extensive chronic GvHD was observed. All patients achieved complete haematological remission. In one patient the fibrosis resolved completely 180 d post transplant. All patients are alive 126, 466 and 764 d after transplantation.
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Affiliation(s)
- Jörg Hessling
- Bone Marrow Transplantation, University Hospital Eppendorf, Hamburg, Germany
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30
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Duggan P, Booth K, Chaudhry A, Stewart D, Ruether JD, Glück S, Morris D, Brown CB, Herbut B, Coppes M, Anderson R, Wolff J, Egeler M, Desai S, Turner AR, Larratt L, Gyonyor E, Russell JA. Unrelated donor BMT recipients given pretransplant low-dose antithymocyte globulin have outcomes equivalent to matched sibling BMT: a matched pair analysis. Bone Marrow Transplant 2002; 30:681-6. [PMID: 12420207 DOI: 10.1038/sj.bmt.1703674] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2002] [Accepted: 05/23/2002] [Indexed: 11/08/2022]
Abstract
Fifty-seven patients receiving unrelated donor (UD) BMT were matched for disease and stage with 57 recipients of genotypically matched related donor (MRD) BMT. All UD recipients were matched serologically for A and B and by high resolution for DR and DQ antigens. All patients received CsA and 'short course' methotrexate with folinic acid. Unrelated donor BMT patients also received thymoglobulin 4.5 mg/kg (6 mg/kg if <30 kg) in divided doses over 3 days pretransplant. For UD and RD BMT, respectively, incidence of acute GVHD grade II-IV was 19 +/- 6% vs 36 +/- 8%, grade III-IV 10 +/- 6% vs 18 +/- 7%, chronic GVHD 44 +/- 8% vs 51 +/- 8%, non-relapse mortality 15 +/- 5% vs 8 +/- 4% at 100 days, 28 +/- 8% vs 36 +/- 7% at 3 years. At 3 years, relapse was 45 +/- 7% vs 42 +/- 7%, and disease-free survival 39 +/- 7% vs 37 +/- 7%. None of these differences are significant. Three-year overall survival was identical at 42 +/- 7%. For 29 patients with low/intermediate risk leukemia, disease-free survival was 68 +/- 10% after UD BMT vs 59 +/- 9% for RD BMT recipients (P = NS). Corresponding figures for high risk patients were 14 +/- 7% and 21 +/- 8%, respectively. We conclude that UD BMT recipients matched as above and given pretransplant ATG have similar outcomes to recipients of MRD BMT using conventional drug prophylaxis. Unrelated donor BMT should be considered in any circumstance where MRD BMT is routine.
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Affiliation(s)
- P Duggan
- Department of Medicine, Foothills Hospital, Calgary, Alberta, Canada
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31
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Pistillo MP, Tazzari PL, Bonifazi F, Bandini G, Kato T, Matsui T, Nishioka K, Conte R, Ferrara GB. Detection of a novel specificity (CTLA-4) in ATG/TMG globulins and sera from ATG-treated leukemic patients. Transplantation 2002; 73:1295-302. [PMID: 11981425 DOI: 10.1097/00007890-200204270-00019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND T-cell costimulation has been shown to provide positive signals for T-cell activation and generation of effector activity. In this study, we analyzed the presence of antibodies (Abs) against the T-lymphocyte costimulatory molecules CD28, CTLA-4, CD80, and CD86 in anti-T-lymphocyte (ATG) and antithymocyte (TMG) globulin preparations to address their mechanism of action. We focused our attention on the role of CTLA-4-specific Abs in the immunosuppressive effect of ATG/TMG, because anti-CTLA-4 agonistic Abs may suppress T-cell proliferation and nonagonistic Abs may lead to T-cell depletion through an Ab-dependent cell cytotoxicity mechanism. METHODS ATG/TMG and patients' sera were tested for binding to recombinant human costimulatory molecules by ELISA techniques. CTLA-4 specificity was also analyzed by cytoplasmic immunofluorescence staining of a CTLA-4 transfectant by competitive inhibition immunofluorescence and by cell proliferation assay in allogeneic mixed lymphocyte reaction (MLR). RESULTS Either ATG or TMG predominantly contained anti-CTLA-4 Abs, with higher reactivity in ATG followed by anti-CD86 and -CD28 Abs, whereas anti-CD80 Abs were found only in ATG. Anti-CTLA-4 Abs present in ATG/TMG recognized the native form of CTLA-4 molecule, and their removal reduced the effect of ATG in an allogeneic MLR. Kinetic studies indicated that such Abs were present in the sera of 12 ATG-treated leukemic patients up to 21 days after ATG administration. CONCLUSIONS These data suggest that the novel anti-CTLA-4 Abs found in ATG may greatly contribute to its immunosuppressive effect, thus accounting for the absence of rejection and exceptionally low incidence of graft-versus-host disease in the group of patients analyzed.
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Affiliation(s)
- Maria Pia Pistillo
- Immunogenetics Laboratory, National Cancer Research Institute, Advanced Biotechnology Center, Genova, Italy.
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32
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Kröger N, Zabelina T, Krüger W, Renges H, Stute N, Rischewski J, Sonnenberg S, Ayuk F, Tögel F, Schade U, Fiegel H, Erttmann R, Löliger C, Zander AR. In vivo T cell depletion with pretransplant anti-thymocyte globulin reduces graft-versus-host disease without increasing relapse in good risk myeloid leukemia patients after stem cell transplantation from matched related donors. Bone Marrow Transplant 2002; 29:683-9. [PMID: 12180114 DOI: 10.1038/sj.bmt.1703530] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
One-hundred and two patients with good risk myeloid leukemia (CML first chronic phase or AML first CR) were transplanted from HLA-related donors after conditioning with (n = 45) or without anti-thymocyte globulin (ATG) (n = 57). One graft failure was observed in the non-ATG and none in the ATG group. The median time to leukocyte engraftment (> 1 x 10(9)/l) was 16 (range 12-33) in the ATG group and 17 days (range 11-29) in the non-ATG group (NS) and for platelet engraftment (> 20 x 10(9)/l) 24 and 19 days (P = 0.002), respectively. Acute GVHD grade II-IV was observed in 47% of the non-ATG and in 20% of the ATG group (P = 0.004). Grade III/IV GVHD occurred in 7% of the ATG and in 32% of the non-ATG group (P = 0.002). Chronic GVHD was seen in 36% and 67% (P = 0.005), respectively. After a median follow-up of 48 months (range 2-128), the 5-year estimated OS is 66% (95% KI: 51-81%) for the ATG group and 59% (95% KI: 46-72%) for the non-ATG group (NS). The 5-year estimated DFS is 64% (95% KI: 50-78%) for ATG and 55% (95% KI: 43-67%) for the non-ATG regimen (NS). The 5-year probability of relapse was 5% in the ATG and 15% in the non-ATG group (NS). ATG as part of the conditioning regimen leads to a significant reduction in GVHD without increase of relapse in patients with myeloid leukemia after stem cell transplantation from HLA-related donors.
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Affiliation(s)
- N Kröger
- Bone Marrow Transplantation, University Hospital, Hamburg-Eppendorf, Martinistrasse 52, D-20246, Hamburg, Germany
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33
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Eiermann TH, Sahm H, Freitag C, Zander AR. The effect of IgM-enriched human Ig and rabbit antithymocyte globulin on the stimulation of mononuclear cells. Scand J Immunol 2001; 54:626-9. [PMID: 11902339 DOI: 10.1046/j.1365-3083.2001.01023.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Whether IgM-enriched intravenous Ig (pentaglobin) is a useful adjunct treatment for graft versus host disease (GvHD) prophylaxis in allogeneic stem-cell transplantation is unclear. Clinical data with the use of a five-agent GvHD prevention regimen, including pentaglobin and antithymocyte globulin (ATG), are encouraging. In vitro both have been reported to modulate alloreactive T cells. We compared their inhibitory effect on the phytohemagglutinin-induced lymphocyte proliferation. ATG blocked the proliferation of lymphocytes at lower doses and much stronger than pentaglobin. The combination of both was not different from ATG alone. In pentaglobin, glucose used as stabiliser, caused the effect. Starting at a concentration of 40 mg/dL glucose, glucose alone showed a dose-dependent inhibition of phytohemaglutinin (PHA)-induced proliferation. For the in vivo application of pentaglobin, the results suggest that pentaglobin does not inhibit the proliferation of T cells.
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Affiliation(s)
- T H Eiermann
- Department of Transfusion Medicine, University Hospital Eppendorf, Hamburg, Germany.
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34
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Bacigalupo A, Lamparelli T, Bruzzi P, Guidi S, Alessandrino PE, di Bartolomeo P, Oneto R, Bruno B, Barbanti M, Sacchi N, Van Lint MT, Bosi A. Antithymocyte globulin for graft-versus-host disease prophylaxis in transplants from unrelated donors: 2 randomized studies from Gruppo Italiano Trapianti Midollo Osseo (GITMO). Blood 2001; 98:2942-7. [PMID: 11698275 DOI: 10.1182/blood.v98.10.2942] [Citation(s) in RCA: 408] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
One hundred nine patients with hematologic malignancies, undergoing bone marrow transplants (BMT) from unrelated donors, were randomized in 2 consecutive trials to receive or not to receive antithymocyte globulin (ATG) in the conditioning regimen, as follows: (A) 54 patients (median age, 28 years; 39% with advanced disease) were randomized to no ATG (n = 25) versus 7.5 mg/kg rabbit ATG (Thymoglobulin; Sangstat, Lyon, France) (n = 29); (B) 55 patients (median age, 31 years, 71% with advanced disease) were randomized to no ATG (n = 28) versus 15 mg/kg rabbit ATG (n = 27). Grade III-IV graft-versus-host disease (GVHD) was diagnosed in 36% versus 41% (P =.8) in the first and in 50% versus 11% (P =.001) in the second trial. Transplant-related mortality (TRM), relapse, and actuarial 3-year survival rates were comparable in both trials. In fact, despite the reduction of GVHD in the second trial, a higher risk for lethal infections (30% vs 7%; P =.02) was seen in the arm given 15 mg/kg ATG. Extensive chronic GVHD developed overall more frequently in patients given no ATG (62% vs 39%; P =.04), as confirmed by multivariate analysis (P =.03). Time to 50 x 10(9)/L platelets was comparable in the first trial (21 vs 24 days; P =.3) and delayed in the ATG arm in the second trial (23 vs 38 days; P =.02). These trials suggest that (1) 15 mg/kg ATG before BMT significantly reduces the risk for grade III-IV acute GVHD, (2) this does not translate to a reduction in TRM because of the increased risk for infections, and (3) though survival is unchanged, extensive chronic GVHD is significantly reduced in patients receiving ATG.
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Eiermann TH, Freitag S, Cortes-Dericks L, Sahm H, Zander AR. Jurkat cell-reactive anti-thymocyte globulin assessed ex vivo by flow cytometry persists three weeks in circulation. JOURNAL OF HEMATOTHERAPY & STEM CELL RESEARCH 2001; 10:385-90. [PMID: 11454313 DOI: 10.1089/152581601750288984] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Rabbit anti-thymocyte globulin (ATG-Fresenius) is a polyclonal anti-serum raised against the lymphoblastic T cell line Jurkat. It is used for in vivo depletion of host and donor T cells for allogeneic stem cell transplantation. After administration of 90 mg/kg prior to transplant, rabbit immunoglobulin G (IgG) remains present for 4-5 weeks, but it is unknown how long T cell-reactive antibodies persist. Therefore, we measured anti-Jurkat antibodies by flow cytometry. The detection limit for Jurkat-reactive antibodies was 0.1 microg/ml rabbit IgG; half-maximal labeling of Jurkat cells required 183 microg/ml rabbit ATG. The mean half-life of Jurkat-reactive antibodies in 7 patients was 4 days. Detectable levels persisted up to 3 weeks with antibody levels equivalent to 0.2-4.1 microg/ml rabbit ATG. Jurkat-reactive antibodies were eliminated two-fold faster than rabbit IgG, as assessed by enzyme-linked immunosorbent assay (ELISA). The results suggest that in patients pretreated with ATG before transplantation, residual anti T-cell antibodies may effectively modulate recovery of T cells generated after transplantation, thereby lowering the incidence of severe GVHD.
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Affiliation(s)
- T H Eiermann
- Department of Transfusion Medicine and Bone Marrow Transplantation Center, University Hospital Eppendorf, Hamburg, Germany.
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Kröger N, Zabelina T, Krüger W, Renges H, Stute N, Schrum J, Kabisch H, Schafhausen P, Jaburg N, Löliger C, Schäfer P, Hinke A, Zander AR. Patient cytomegalovirus seropositivity with or without reactivation is the most important prognostic factor for survival and treatment-related mortality in stem cell transplantation from unrelated donors using pretransplant in vivo T-cell depletion with anti-thymocyte globulin. Br J Haematol 2001; 113:1060-71. [PMID: 11442503 DOI: 10.1046/j.1365-2141.2001.02849.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We evaluated the cytomegalovirus (CMV) serostatus as a risk factor for survival and treatment-related mortality (TRM) in 125 patients allografted from an unrelated donor between 1994 and 1999. All patients received pretransplant in vivo T-cell depletion using rabbit anti-thymocyte globulin (ATG). Only one patient had primary graft failure and severe grade III/IV graft-versus-host disease occurred in 14% of the patients. The overall survival (OS) at 3 years was 70% for CMV-negative patients (n = 76) and 29% in the seropositive cohort (n = 49) (P > 0.001). In multivariate analyses, CMV seropositivity remained an independent negative prognostic factor for OS (RR: 2.1; CI: 1.2-3.8; P = 0.014), apart from age > 20 years (RR: 2.74; CI: 1.2-3.8; P = 0.004) and late leucocyte engraftment (RR: 2.4; CI: 1.2-4.9; P = 0.015). The TRM for all patients was 27%. Despite monitoring for CMV antigenaemia and preemptive therapy with ganciclovir when reactivation occurred, seropositive patients had a three times higher risk of fatal treatment-related complications than seronegative patients. In multivariate analyses, CMV seropositivity remained the strongest independent negative factor for TRM (RR: 5.3; CI: 1.9-14.6; P = 0.002), followed by age > 20 years (RR: 4.8; CI: 1.3-18.1; P = 0.02) and delayed leucocyte engraftment (RR: 3.6; CI: 1.2-11; P = 0.02). The TRM was identical in seropositive patients with (n = 27) or without (n = 22) CMV reactivation (44% versus 50%). We conclude that CMV seropositivity, despite preemptive ganciclovir therapy and even without reactivation, is a major negative prognostic factor for survival as well as for TRM in unrelated stem cell transplantation using pretransplant in vivo T-cell depletion with ATG.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Antilymphocyte Serum/administration & dosage
- Child
- Child, Preschool
- Cytomegalovirus
- Cytomegalovirus Infections/complications
- Female
- Hematopoietic Stem Cell Transplantation/mortality
- Humans
- Infant
- Leukemia/therapy
- Leukemia/virology
- Leukemia, Myeloid/therapy
- Leukemia, Myeloid/virology
- Leukemia, Myeloid, Accelerated Phase/therapy
- Leukemia, Myeloid, Accelerated Phase/virology
- Leukemia, Myeloid, Chronic-Phase/therapy
- Leukemia, Myeloid, Chronic-Phase/virology
- Leukemia, Myelomonocytic, Acute/therapy
- Leukemia, Myelomonocytic, Acute/virology
- Lymphoma/therapy
- Lymphoma/virology
- Male
- Middle Aged
- Multiple Myeloma/therapy
- Multiple Myeloma/virology
- Multivariate Analysis
- Myelodysplastic Syndromes/therapy
- Myelodysplastic Syndromes/virology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/virology
- Risk Factors
- Survival Rate
- Transplantation Conditioning/methods
- Transplantation, Homologous
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Affiliation(s)
- N Kröger
- Bone Marrow Transplantation, University Hospital Hamburg, Department of Bone Marrow Transplantation, Pavlow University, St Petersburg, Russia.
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Kröger N, Zabelina T, Krüger W, Renges H, Stute N, Kabisch H, Jaburg N, Löliger C, Krüll A, Zander AR. Comparison of total body irradiation vs busulfan in combination with cyclophosphamide as conditioning for unrelated stem cell transplantation in CML patients. Bone Marrow Transplant 2001; 27:349-54. [PMID: 11313663 DOI: 10.1038/sj.bmt.1702802] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2000] [Accepted: 07/31/2000] [Indexed: 11/08/2022]
Abstract
We compared fractionated total body irradiation (12 Gy)/cyclophosphamide (120 mg/kg) with busulfan (16 mg/kg)/cyclophosphamide (120 mg/kg) as preparative therapy in unrelated donor stem cell transplantation of CML patients. Fifty patients with CML (1.CP = 46; aP = 4) and a median age of 36 years (range 16-52) were enrolled in this sequential trial between 1994 and 1999. In both groups patients were well balanced with respect to age, disease status, stem cell source and CMV status. All patients received standard doses of cyclosporin A, methotrexate and anti-thymocyte globulin (ATG) as GVHD prophylaxis. No graft failures occurred in either group. The median day of leukocyte engraftment was earlier in the Bu/Cy than in the TBI/Cy group (day 15 vs 17; P = 0.006). The incidence of grade II-IV GVHD was 40% in the TBI/Cy and 36% in the Bu/Cy group, whereas severe grade III/IV GVHD was only observed in 12% of patients in both groups. The incidence of chronic GVHD (limited and extensive) at 1 year was higher in the Bu/Cy arm (65% vs 30%; P = 0.02). More toxicity grade I/II of the liver (88% vs 44%; P = 0.002) and more hemorrhagic cystitis (32% vs 8%; P = 0.02) were observed in the Bu/Cy regimen. Seven relapses in the TBI and no relapse in the Bu/Cy group were observed after a median follow-up of 44 and 15 months, respectively. The estimated 3 year OS and DFS was 72% (95% CI: 55-98%) and 58% (95% CI: 39-77%) in the TBI and 70% (95% CI: 51-89%) for DFS and OS in the Bu/Cy group. We conclude that the anti-leukemic effect of the Bu/Cy regimen seems to be at least as effective as the TBI/Cy combination in unrelated stem cell transplantation of CML patients, with no graft failures, but that it correlates with a higher incidence of liver toxicity, hemorrhagic cystitis and chronic GVHD. Longer follow-up is necessary to determine the late relapse rate and late toxicity.
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MESH Headings
- Adolescent
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/toxicity
- Busulfan/administration & dosage
- Busulfan/toxicity
- Cyclophosphamide/administration & dosage
- Cyclophosphamide/toxicity
- Disease-Free Survival
- Female
- Graft Survival
- Graft vs Host Disease/etiology
- Hematopoietic Stem Cell Transplantation/methods
- Hematopoietic Stem Cell Transplantation/mortality
- Hematopoietic Stem Cell Transplantation/standards
- Humans
- Immunosuppressive Agents/therapeutic use
- Immunosuppressive Agents/toxicity
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/complications
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/radiotherapy
- Male
- Middle Aged
- Transplantation Conditioning/methods
- Transplantation Conditioning/standards
- Transplantation, Homologous/methods
- Transplantation, Homologous/mortality
- Transplantation, Homologous/standards
- Whole-Body Irradiation/adverse effects
- Whole-Body Irradiation/standards
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Affiliation(s)
- N Kröger
- Bone Marrow Transplantation, University-Hospital Hamburg, Germany
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38
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Wolff SN. Hematopoietic cell transplant from volunteer unrelated or partially matched related donors: recent developments. Curr Opin Organ Transplant 2000. [DOI: 10.1097/00075200-200012000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Kröger N, Zabelina T, Sonnenberg S, Krüger W, Renges H, Stute N, Finkenstein F, Mayer U, Holstein K, Fiedler W, Colberg H, Sonnen R, Kuse R, Braumann D, Metzner B, del Valle F, Erttmann R, Kabisch H, Zander AR. Dose-dependent effect of etoposide in combination with busulfan plus cyclophosphamide as conditioning for stem cell transplantation in patients with acute myeloid leukemia. Bone Marrow Transplant 2000; 26:711-6. [PMID: 11042650 DOI: 10.1038/sj.bmt.1702598] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To evaluate the efficacy and toxicity of two different etoposide (VP-16) dosages (30 or 45 mg/kg) in combination with busulfan/cyclophosphamide as conditioning therapy followed by stem cell transplantation in acute myeloid leukemia (AML), 90 patients with AML received either 30 mg/kg (n = 60) or 45 mg/kg (n = 30) etoposide in combination with busulfan (16 mg/kg) and cyclophosphamide (120 mg/kg). The stem cell source was allogeneic related bone marrow (BM) (n = 53), allogeneic unrelated BM (n = 5), allogeneic unrelated peripheral blood (PBSC) (n = 2), syngeneic BM (n = 2), autologous BM purged (n = 9) or unpurged (n = 9), autologous PBSC (n = 10). Fifty-six patients (62%) were in first CR, 26 (29%) were > first CR, and eight (9%) were transplanted in relapse. Principal toxicities in both groups were mucositis and hepatotoxicity. Forty-five mg/kg etoposide resulted in greater hepatic toxicity (P = 0.03), and a higher incidence of VOD (23 vs 12%, P = 0.04) and acute GVHD grade III/IV (13 vs 5%, NS). The treatment-related mortality was 17% in the 30 mg/kg group and 33% in the 45 mg/kg group, mainly due to infections, intestinal pneumonia and GVHD. Hematological recovery of leukocytes 1/nl was comparable in both groups (17 vs 16 days). After a median follow-up of 16 months 19% in the 30 mg/kg group and 23% in the 45 mg/kg group relapsed. In patients who had undergone allogeneic related bone marrow transplantation in first CR no relapses occurred after a median follow-up of 3 years. For all patients the 3-year estimated disease-free survival was 62% in the 30 mg/kg group and 40% in the 45 mg/kg group (P = 0.03). For patients in first CR who underwent allogeneic related stem cell transplantation the 3 year disease-free survivals were 80% and 66%, respectively (P = 0.4). We conclude that etoposide 30 mg/kg or 45 mg/kg in combination with busulfan/cyclophosphamide is a highly active regimen for bone marrow transplantation of patients with AML with a low relapse rate. However, conditioning with 30 mg/kg rather than 45 mg/kg etoposide resulted in less toxicity and a better overall survival due to a lower transplant-related mortality. Bone Marrow Transplantation (2000) 26, 711-716.
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Affiliation(s)
- N Kröger
- Bone Marrow Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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