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Oza K, Kang J, Patil D, Owen KL, Cui W, Khan K, Kaufman SS, Kroemer A. Current Advances in Graft-versus-host Disease After Intestinal Transplantation. Transplantation 2024; 108:399-408. [PMID: 37309025 DOI: 10.1097/tp.0000000000004703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Graft-versus-host disease (GvHD) remains a potentially fatal complication following intestinal transplant (ITx). Over the past decade, advances in the understanding of the pathophysiology of this complex immunological phenomenon have led to the reassessment of the host systemic immune response and have created a gateway for novel preventive and therapeutic strategies. Although sufficient evidence dictates the use of corticosteroids as a first-line option, the treatment for refractory disease remains contentious and lacks a standardized therapeutic approach. Timely diagnosis remains crucial, and the advent of chimerism detection and immunological biomarkers have transformed the identification, prognostication, and potential for survival after GvHD in ITx. The objectives of the following review aim to discuss the clinical and diagnostic features, pathophysiology, advances in immune biomarkers, as well as therapeutic opportunities in the prevention and treatment of GvHD in ITx.
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Affiliation(s)
- Kesha Oza
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Digvijay Patil
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Kathryn L Owen
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Wanxing Cui
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
- Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Stuart S Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
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2
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Wang YM, Abdullah S, Luebbering N, Langenberg L, Duell A, Lake K, Lane A, Hils B, Vazquez Silva O, Trapp M, Nalapareddy K, Koo J, Denson LA, Jodele S, Haslam DB, Faubion WA, Davies SM, Khandelwal P. Intestinal permeability in patients undergoing stem cell transplantation correlates with systemic acute phase responses and dysbiosis. Blood Adv 2023; 7:5137-5151. [PMID: 37083597 PMCID: PMC10480541 DOI: 10.1182/bloodadvances.2023009960] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023] Open
Abstract
Intestinal permeability may correlate with adverse outcomes during hematopoietic stem cell transplantation (HSCT), but longitudinal quantification with traditional oral mannitol and lactulose is not feasible in HSCT recipients because of mucositis and diarrhea. A modified lactulose:rhamnose (LR) assay is validated in children with environmental enteritis. Our study objective was to quantify peri-HSCT intestinal permeability changes using the modified LR assay. The LR assay was administered before transplant, at day +7 and +30 to 80 pediatric and young adult patients who received allogeneic HSCT. Lactulose and rhamnose were detected using urine mass spectrometry and expressed as an L:R ratio. Metagenomic shotgun sequencing of stool for microbiome analyses and enzyme-linked immunosorbent assay analyses of plasma lipopolysaccharide binding protein (LBP), ST2, REG3α, claudin1, occludin, and intestinal alkaline phosphatase were performed at the same timepoints. L:R ratios were increased at day +7 but returned to baseline at day +30 in most patients (P = .014). Conditioning regimen intensity did not affect the trajectory of L:R (P = .39). Baseline L:R ratios did not vary with diagnosis. L:R correlated with LBP levels (r2 = 0.208; P = .0014). High L:R ratios were associated with lower microbiome diversity (P = .035), loss of anaerobic organisms (P = .020), and higher plasma LBP (P = .0014). No adverse gastrointestinal effects occurred because of LR. Intestinal permeability as measured through L:R ratios after allogeneic HSCT correlates with intestinal dysbiosis and elevated plasma LBP. The LR assay is well-tolerated and may identify transplant recipients who are more likely to experience adverse outcomes.
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Affiliation(s)
- YunZu Michele Wang
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Sheyar Abdullah
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Nathan Luebbering
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lucille Langenberg
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Alexandra Duell
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kelly Lake
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adam Lane
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Brian Hils
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Ormarie Vazquez Silva
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Monica Trapp
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kodandaramireddy Nalapareddy
- Division of Experimental Hematology and Cancer Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jane Koo
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lee A. Denson
- University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - David B. Haslam
- University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Stella M. Davies
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| | - Pooja Khandelwal
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
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3
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Ngwube A, Rangarajan H, Shah N. Role of abatacept in the prevention of graft- versus-host disease: current perspectives. Ther Adv Hematol 2023; 14:20406207231152644. [PMID: 36845849 PMCID: PMC9943961 DOI: 10.1177/20406207231152644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 11/28/2022] [Indexed: 02/11/2023] Open
Abstract
Administration of abatacept following transplantation has been reported to inhibit graft rejection and graft-versus-host-disease (GvHD) in mouse models associated with allogeneic hematopoietic stem cell transplant (HSCT). This strategy has recently been adopted in clinical practice for GvHD prevention in human allogeneic HSCT and offers a unique approach to optimizing GvHD prophylaxis following alternative donor HSCTs. When combined with calcineurin inhibitors and methotrexate, abatacept had shown to be safe and effective in preventing moderate to severe acute GvHD in myeloablative HSCT using human leukocyte antigen (HLA) unrelated donors. Equivalent results are being reported in recent studies using alternative donors, in reduced-intensity conditioning HSCT and nonmalignant disorders. These observations have led to hypothesizing that even in the setting of increasing donor HLA disparity, abatacept when given with traditional GvHD prophylaxis does not worsen general outcomes. In addition, in limited studies, abatacept have being protective against the development of chronic GvHD through extended dosing and in the treatment of steroid-refractory chronic GvHD. This review summarized all the limited reports of this novels approach in the HSCT setting.
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Affiliation(s)
| | - Hemalatha Rangarajan
- Division of Pediatric Hematology, Oncology,
Blood and Marrow Transplant, Nationwide Children’s Hospital, Columbus, OH,
USA
| | - Niketa Shah
- Section of Pediatric Hematology Oncology and
Bone Marrow transplant, Yale School of Medicine, New Haven, CT, USA
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4
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Eckrich MJ, Frangoul H. Gene Editing for Sickle Cell Disease and Transfusion Dependent Thalassemias- A cure within reach. Semin Hematol 2022; 60:3-9. [PMID: 37080708 DOI: 10.1053/j.seminhematol.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/19/2022] [Indexed: 01/02/2023]
Abstract
Sickle cell disease (SCD) is associated with significant morbidity and shortened life expectancy. Similarly, patients with transfusion dependent beta thalassemia (TdT) require life-long transfusion therapy, chelation therapy and significant organ dysfunction. Allogeneic transplantation from a matched family donor provided the only curative option for patients with SCD and TdT. Unfortunately, less than 20% of patients have a fully matched related donor and results using unrelated donor transplant were associated with high rate of complications. Ex vivo gene therapy through globin gene addition has been investigated extensively and recent encouraging preliminary data resulted in regulatory approval in patients with TdT. Recent improvements in our understanding of the molecular pathways controlling erythropoiesis and globin switching from fetal hemoglobin to adult hemoglobin offer a new and exciting therapeutic options. Rapid and substantial advances in genome editing tools using CRISPR/Cas9, have raised the possibility of genetic editing and correction in patient derived hematopoietic stem and progenitor cells. We will review results of gene editing approach that can induce fetal hemoglobin production in patients with SCD and TdT.
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Abatacept-based Graft-Versus-Host Disease Prophylaxis in Haplo-identical Hematopoietic Cell Transplant in a High-risk Cohort. J Pediatr Hematol Oncol 2022; 44:383-387. [PMID: 35129143 DOI: 10.1097/mph.0000000000002421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/04/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is insufficient guidance in using posttransplant cyclophosphamide in patients with organ dysfunctions. Abatacept (Aba), a T cell costimulation blockade, has recently been shown to prevent severe acute graft-versus-host disease (GVHD). OBSERVATION We report adding Aba as GVHD prophylaxis in 4 pediatrics patients who received haplo-hematopoietic cell transplantation. Two patients had grade 2 acute GVHD and 2 had mild chronic GVHD. All 4 patients are alive with full donor chimerism, and 3 are off immunosuppressants. CONCLUSION An Aba-based regimen can result in reliable engraftment and acceptable GVHD when concerns of organ dysfunction prevents the use of posttransplant cyclophosphamide in haplo-hematopoietic cell transplantation.
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Michniacki TF, Choi SW, Peltier DC. Immune Suppression in Allogeneic Hematopoietic Stem Cell Transplantation. Handb Exp Pharmacol 2022; 272:209-243. [PMID: 34628553 PMCID: PMC9055779 DOI: 10.1007/164_2021_544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment for high-risk hematologic disorders. There are multiple immune-mediated complications following allo-HSCT that are prevented and/or treated by immunosuppressive agents. Principal among these immune-mediated complications is acute graft-versus-host disease (aGVHD), which occurs when the new donor immune system targets host tissue antigens. The immunobiology of aGVHD is complex and involves all aspects of the immune system. Due to the risk of aGVHD, immunosuppressive aGVHD prophylaxis is required for nearly all allogeneic HSCT recipients. Despite prophylaxis, aGVHD remains a major cause of nonrelapse mortality. Here, we discuss the clinical features of aGVHD, the immunobiology of aGVHD, the immunosuppressive therapies used to prevent and treat aGVHD, how to mitigate the side effects of these immunosuppressive therapies, and what additional immune-mediated post-allo-HSCT complications are also treated with immunosuppression.
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Affiliation(s)
- Thomas F Michniacki
- Division of Hematology/Oncology, Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA
| | - Sung Won Choi
- Division of Hematology/Oncology, Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA.
| | - Daniel C Peltier
- Division of Hematology/Oncology, Department of Pediatrics, Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI, USA.
- University of Michigan Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA.
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Wright M, Rangarajan H, Abu-Arja R, Auletta JJ, Lee D, Polishchuk V, Pai V, Taylor K, Bajwa RPS. Use of belatacept as alternative graft vs host disease prophylaxis in pediatric allogeneic hematopoietic stem cell transplantation. Pediatr Transplant 2021; 25:e14041. [PMID: 34014014 DOI: 10.1111/petr.14041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/13/2021] [Accepted: 04/28/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Immunosuppressive prophylaxis is usually given to decrease the development of acute graft versus host disease (GvHD) after allogeneic hematopoietic stem cell transplantation (HSCT). Belatacept is a Cytotoxic T-lymphocyte-associated protein 4, blocking agent, an immunosuppressive agent used for organ rejection prevention in adult renal transplant recipients. METHODS We describe two children in whom belatacept was successfully used for GvHD prophylaxis. Case 1 was noncompliant with prior immunosuppressive therapy for aplastic anemia, and Case 2 developed severe thrombotic microangiopathy (TMA) precluding the use of calcineurin inhibitors (CNI) or mTOR inhibitors. RESULTS AND CONCLUSION Belatacept was found to be a safe alternative in preventing GvHD in 2 patients in whom traditional prophylactic therapies were not possible to use.
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Affiliation(s)
- Mariah Wright
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Hemalatha Rangarajan
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rolla Abu-Arja
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jeffery J Auletta
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dean Lee
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Veronika Polishchuk
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Vinita Pai
- Department of Clinical Pharmacy, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kimberly Taylor
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rajinder P S Bajwa
- Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
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Koniali L, Lederer CW, Kleanthous M. Therapy Development by Genome Editing of Hematopoietic Stem Cells. Cells 2021; 10:1492. [PMID: 34198536 PMCID: PMC8231983 DOI: 10.3390/cells10061492] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
Accessibility of hematopoietic stem cells (HSCs) for the manipulation and repopulation of the blood and immune systems has placed them at the forefront of cell and gene therapy development. Recent advances in genome-editing tools, in particular for clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein (Cas) and CRISPR/Cas-derived editing systems, have transformed the gene therapy landscape. Their versatility and the ability to edit genomic sequences and facilitate gene disruption, correction or insertion, have broadened the spectrum of potential gene therapy targets and accelerated the development of potential curative therapies for many rare diseases treatable by transplantation or modification of HSCs. Ongoing developments seek to address efficiency and precision of HSC modification, tolerability of treatment and the distribution and affordability of corresponding therapies. Here, we give an overview of recent progress in the field of HSC genome editing as treatment for inherited disorders and summarize the most significant findings from corresponding preclinical and clinical studies. With emphasis on HSC-based therapies, we also discuss technical hurdles that need to be overcome en route to clinical translation of genome editing and indicate advances that may facilitate routine application beyond the most common disorders.
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Affiliation(s)
- Lola Koniali
- Department of Molecular Genetics Thalassemia, The Cyprus Institute of Neurology and Genetics, Nicosia 2371, Cyprus; (L.K.); (M.K.)
| | - Carsten W. Lederer
- Department of Molecular Genetics Thalassemia, The Cyprus Institute of Neurology and Genetics, Nicosia 2371, Cyprus; (L.K.); (M.K.)
- Cyprus School of Molecular Medicine, Nicosia 2371, Cyprus
| | - Marina Kleanthous
- Department of Molecular Genetics Thalassemia, The Cyprus Institute of Neurology and Genetics, Nicosia 2371, Cyprus; (L.K.); (M.K.)
- Cyprus School of Molecular Medicine, Nicosia 2371, Cyprus
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Russell AL, Prince C, Lundgren TS, Knight KA, Denning G, Alexander JS, Zoine JT, Spencer HT, Chandrakasan S, Doering CB. Non-genotoxic conditioning facilitates hematopoietic stem cell gene therapy for hemophilia A using bioengineered factor VIII. Mol Ther Methods Clin Dev 2021; 21:710-727. [PMID: 34141826 PMCID: PMC8181577 DOI: 10.1016/j.omtm.2021.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/29/2021] [Indexed: 01/09/2023]
Abstract
Hematopoietic stem and progenitor cell (HSPC) lentiviral gene therapy is a promising strategy toward a lifelong cure for hemophilia A (HA). The primary risks associated with this approach center on the requirement for pre-transplantation conditioning necessary to make space for, and provide immune suppression against, stem cells and blood coagulation factor VIII, respectively. Traditional conditioning agents utilize genotoxic mechanisms of action, such as DNA alkylation, that increase risk of sterility, infection, and developing secondary malignancies. In the current study, we describe a non-genotoxic conditioning protocol using an immunotoxin targeting CD117 (c-kit) to achieve endogenous hematopoietic stem cell depletion and a cocktail of monoclonal antibodies to provide transient immune suppression against the transgene product in a murine HA gene therapy model. This strategy provides high-level engraftment of hematopoietic stem cells genetically modified ex vivo using recombinant lentiviral vector (LV) encoding a bioengineered high-expression factor VIII variant, termed ET3. Factor VIII procoagulant activity levels were durably elevated into the normal range and phenotypic correction achieved. Furthermore, no immunological rejection or development of anti-ET3 immunity was observed. These preclinical data support clinical translation of non-genotoxic antibody-based conditioning in HSPC LV gene therapy for HA.
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Affiliation(s)
- Athena L. Russell
- Graduate Program in Genetics and Molecular Biology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | - Chengyu Prince
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Taran S. Lundgren
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | - Kristopher A. Knight
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Graduate Program in Molecular and Systems Pharmacology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | | | - Jordan S. Alexander
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Jaquelyn T. Zoine
- Graduate Program in Cancer Biology, Laney Graduate School, Emory University, Atlanta, GA 30322, USA
| | - H. Trent Spencer
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Expression Therapeutics, LLC, Tucker, GA 30084, USA
| | - Shanmuganathan Chandrakasan
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Christopher B. Doering
- Aflac Cancer and Blood Disorders Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
- Expression Therapeutics, LLC, Tucker, GA 30084, USA
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10
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Hayashi RJ. Considerations in Preparative Regimen Selection to Minimize Rejection in Pediatric Hematopoietic Transplantation in Non-Malignant Diseases. Front Immunol 2020; 11:567423. [PMID: 33193340 PMCID: PMC7604384 DOI: 10.3389/fimmu.2020.567423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/25/2020] [Indexed: 01/19/2023] Open
Abstract
The variables that influence the selection of a preparative regimen for a pediatric hematopoietic stem cell transplant procedure encompasses many issues. When one considers this procedure for non-malignant diseases, components in a preparative regimen that were historically developed to reduce malignant tumor burden may be unnecessary. The primary goal of the procedure in this instance becomes engraftment with the establishment of normal hematopoiesis and a normal immune system. Overcoming rejection becomes the primary priority, but pursuit of this goal cannot neglect organ toxicity, or post-transplant morbidity such as graft-versus-host disease or life threatening infections. With the improvements in supportive care, newborn screening techniques for early disease detection, and the expansion of viable donor sources, we have reached a stage where hematopoietic stem cell transplantation can be considered for virtually any patient with a hematopoietic based disease. Advancing preparative regiments that minimize rejection and transplant related toxicity will thus dictate to what extent this medical technology is fully utilized. This mini-review will provide an overview of the origins of conditioning regimens for transplantation and how agents and techniques have evolved to make hematopoietic stem cell transplantation a viable option for children with non-malignant diseases of the hematopoietic system. We will summarize the current state of this facet of the transplant procedure and describe the considerations that come into play in selecting a particular preparative regimen. Decisions within this realm must tailor the treatment to the primary disease condition to ideally achieve an optimal outcome. Finally, we will project forward where advances are needed to overcome the persistent engraftment obstacles that currently limit the utilization of transplantation for haematopoietically based diseases in children.
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Affiliation(s)
- Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, MO, United States
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11
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Vandenhove B, Canti L, Schoemans H, Beguin Y, Baron F, Graux C, Kerre T, Servais S. How to Make an Immune System and a Foreign Host Quickly Cohabit in Peace? The Challenge of Acute Graft- Versus-Host Disease Prevention After Allogeneic Hematopoietic Cell Transplantation. Front Immunol 2020; 11:583564. [PMID: 33193397 PMCID: PMC7609863 DOI: 10.3389/fimmu.2020.583564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/21/2020] [Indexed: 01/16/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (alloHCT) has been used as cellular immunotherapy against hematological cancers for more than six decades. Its therapeutic efficacy relies on the cytoreductive effects of the conditioning regimen but also on potent graft-versus-tumor (GVT) reactions mediated by donor-derived immune cells. However, beneficial GVT effects may be counterbalanced by acute GVHD (aGVHD), a systemic syndrome in which donor immune cells attack healthy tissues of the recipient, resulting in severe inflammatory lesions mainly of the skin, gut, and liver. Despite standard prophylaxis regimens, aGVHD still occurs in approximately 20–50% of alloHCT recipients and remains a leading cause of transplant-related mortality. Over the past two decades, advances in the understanding its pathophysiology have helped to redefine aGVHD reactions and clinical presentations as well as developing novel strategies to optimize its prevention. In this review, we provide a brief overview of current knowledge on aGVHD immunopathology and discuss current approaches and novel strategies being developed and evaluated in clinical trials for aGVHD prevention. Optimal prophylaxis of aGVHD would prevent the development of clinically significant aGVHD, while preserving sufficient immune responsiveness to maintain beneficial GVT effects and immune defenses against pathogens.
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Affiliation(s)
- Benoît Vandenhove
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium
| | - Lorenzo Canti
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium
| | - Hélène Schoemans
- Department of Clinical Hematology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Yves Beguin
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium.,Department of Clinical Hematology, CHU of Liège, University of Liège, Liège, Belgium
| | - Frédéric Baron
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium.,Department of Clinical Hematology, CHU of Liège, University of Liège, Liège, Belgium
| | - Carlos Graux
- Department of Clinical Hematology, CHU UCL Namur (Godinne), Université Catholique de Louvain, Yvoir, Belgium
| | - Tessa Kerre
- Hematology Department, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Sophie Servais
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium.,Department of Clinical Hematology, CHU of Liège, University of Liège, Liège, Belgium
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