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Sharaf El-Deen MO, Soliman MM, Al-Azab G, Samra M, Shams MEE. Post-transplantation cyclophosphamide and cyclosporine A versus methotrexate and cyclosporine A for graft-versus-host disease prophylaxis after allogeneic peripheral stem cell transplantation in adult acute myeloid leukemia patients. Toxicol Appl Pharmacol 2024; 491:117071. [PMID: 39159847 DOI: 10.1016/j.taap.2024.117071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 08/09/2024] [Accepted: 08/13/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Different prophylactic protocols are available for preventing graft-versus-host disease (GVHD) after matched sibling donor (MSD) allogeneic hematopoietic cell transplantation (allo-HCT). This study aimed to compare the effectiveness of post-transplantation cyclophosphamide plus cyclosporine A (PT-CY/CSA) versus methotrexate plus CSA (MTX/CSA) as GVHD prophylaxis protocols in adult acute myeloid leukemia (AML) patients who received peripheral blood stem cells (PBSC) from fully matched donors. METHODS The 1-year outcomes of 89 patients treated with PT-CY/CSA and 90 patients treated with MTX/CSA who had MSD allo-HCT for AML using unmanipulated mobilized PBSC were examined and compared. RESULTS The cumulative incidence of acute GVHD at 100 days was considerably lower in the PT-CY/CSA group (4% vs 19.3%, p = 0.002), however there were no statistically significant difference in the cumulative incidence of chronic GVHD at 1-year (19.6% vs 37.4%, p = 0.053). Significant delays in neutrophil and platelet engraftments were reported in the PT-CY/CSA group (17 vs 12 days) and (13 vs 12 days), respectively (p < 0.001). The cumulative incidences of relapse (19.1% vs 13.7%, p = 0.470), overall survival (79.1% vs 77.3%, p = 0.986), non-relapse mortality (16.5% vs 16.8%, p = 0.837), and the GVHD and relapse-free survival (GRFS) (53.7% vs 46.6%, p = 0.478) did not differ statistically at 1-year. CONCLUSION PT-CY/CSA demonstrated a significant decrease in the rate of acute GVHD. However, it was associated with engraftment delay.
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Affiliation(s)
- Mustafa O Sharaf El-Deen
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Moetaza M Soliman
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt.
| | - Gamal Al-Azab
- Clinical Pharmacy Department, Faculty of Pharmacy, Tanta University, Tanta, Egypt
| | - Mohamed Samra
- Medical Oncology and Hematology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohammad E E Shams
- Clinical Pharmacy and Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
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Kim D, Taparia M, Robinson E, Mcgee M, Merali T. Navigating the Complexity of Chronic Graft-vs-Host Disease: Canadian Insights into Real-World Treatment Sequencing. Transplant Proc 2024; 56:409-415. [PMID: 38342748 DOI: 10.1016/j.transproceed.2023.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 12/28/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND Graft-vs-Host Disease (GVHD) is a donor immune-mediated syndrome occurring in patients who undergo an allogeneic hematopoietic cell transplant (HCT). Chronic GVHD (cGVHD) presents with complications of variable severity. Corticosteroids are standard first-line (1L) treatment, but the sequence after 1L is unclear with the availability of new treatments. This research aimed to understand real-world treatment sequencing for cGVHD. METHODS This retrospective study investigated adult patients across 7 treatment sites in Canada who had received an allogeneic HCT >18 months prior to the study, experienced cGVHD, and received systemic treatment, including extracorporeal photopheresis (ECP). RESULTS A total of 77 cases were reviewed retrospectively (median age = 51 (IQR 41-62), 51% female). 59 patients remained on active systemic treatment, and among this group, the most common treatments in use were corticosteroids (47%) and ruxolitinib (47%). One patient died, and 17 patients were on non-systemic treatment after complications resolved. The median lines of treatment (LOT) received was 2 (IQR 1-3), with 39% of patients having received >2 LOT. Among patients with lung complications (n = 24), 41% had received 3 or more LOT. Among patients with scleroderma (n = 22), 77% had received 3 or more LOT, 23% of which had received 6 or more unique treatments. CONCLUSIONS The first treatment given to cGVHD patients was corticosteroids. Ruxolitinib was the most used second-line treatment. About 40% of cGVHD patients received >2 treatments, and scleroderma was associated with more LOT. There is a need for more effective cGVHD treatment options when early treatments fail to resolve complications.
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Affiliation(s)
- Dennis Kim
- Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Minakshi Taparia
- University of Alberta Health Sciences Centre, Edmonton, Alberta, Canada
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Ali MM, Gedde-Dahl T, Osnes LT, Perrier F, Veierød MB, Tjønnfjord GE, Iversen PO. Extracorporeal photopheresis as graft-versus-host disease prophylaxis: a randomized controlled trial: Prophylactic extracorporeal photopheresis to prevent graft-versus-host disease. Transplant Cell Ther 2023:S2666-6367(23)01133-8. [PMID: 36878428 DOI: 10.1016/j.jtct.2023.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only curative option for many patients diagnosed with hematological malignancies. A major obstacle is graft-versus-host disease (GvHD) causing significant morbidity and mortality. Extracorporeal photopheresis (ECP) is an increasingly applied GvHD treatment, partly due to its favourable safety profile. In contrast, the use of ECP in preventing GvHD is sparse, and randomized controlled trials (RCTs) are lacking. OBJECTIVE We therefore conducted a RCT to assess if ECP applied post-transplant, could prevent the development of GvHD within the first year of transplantation. STUDY DESIGN We enrolled 157 patients (18-74 years) with a hematological malignancy receiving first allo-HSCT: 76 randomized to the intervention group and 81 to the control group. ECP was initiated directly upon engraftment and was planned twice weekly for two weeks, then once weekly for four weeks. GvHD, relapse, and death were analyzed with Cox regression analysis. RESULTS During the first year, 45 patients in the intervention and 52 control patients developed GvHD (HR=0.82, 95% CI 0.55-1.22, P=0.32). There were no differences in acute or chronic GvHD or its organ distribution in this intention-to-treat RCT. A per-protocol analysis revealed a significant difference in GvHD between the intervention (per-protocol; n=39 of 76) and the control group (n=77), 46% vs 68%, respectively, (HR 0.47, 95% CI 0.27-0.80, P=0.006). Relapse occurred in 15 patients in the intervention group and in 11 patients among the controls (HR=1.38, 95% CI 0.64-3.01, P=0.42). GvHD-free relapse-free (GRFS) survival, event-free survival, overall survival and non-relapse mortality did not differ significantly between the two study groups. No significant difference in immune reconstitution between the two study groups was revealed. CONCLUSION This first intention-to-treat RCT, investigating ECP as GvHD prophylaxis in allo-HSCT for hematological malignancy does not support the use of ECP as adjunct to standard drug-based GvHD-prophylaxis. This trial was registered at www. CLINICALTRIALS gov as #NCT03204721.
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Affiliation(s)
- Maryan M Ali
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute for Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Tobias Gedde-Dahl
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Liv T Osnes
- Department of Immunology, Oslo University Hospital, Oslo, Norway
| | - Flavie Perrier
- Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Marit B Veierød
- Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Per O Iversen
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Department of Nutrition, University of Oslo, Oslo, Norway
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Nakamura N, Wada F, Kondo T, Aoki K, Arai Y, Mizumoto C, Kanda J, Kitawaki T, Yamashita K, Takaori-Kondo A. Significance of Omitting Day 11 Mini-Dose Methotrexate for GVHD Prophylaxis After Unrelated Bone Marrow Transplantation. Transplant Cell Ther 2023; 29:119.e1-119.e7. [PMID: 36372357 DOI: 10.1016/j.jtct.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/12/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Abstract
The combination of calcineurin inhibitors and short-term methotrexate has been used as a standard graft-versus-host-disease (GVHD) prophylaxis in allogeneic hematopoietic stem cell transplantation. Mini-dose methotrexate (mini-MTX), consisting of 5 mg/m2/d on days 1, 3, 6, and 11, is occasionally selected as an alternative considering toxicity. The significance of day 11 administration remains unclear. We performed a retrospective study of 135 cases of unrelated bone marrow transplantation at our institute between 2006 and 2019 and compared the outcomes between day 11 MTX dose omitted (n = 72) and full-doses of mini-MTX (n = 63). In total cohort, the 4-year overall survival (OS) was 58.7 %, and the omitted group showed poor GVHD/relapse-free-survival (P = .01) with comparable OS (P = .11) and relapse-free survival (P = .11). Human leukocyte antigen (HLA) mismatch is a major risk factor for severe GVHD. We analyzed the impact of omitting day 11 MTX in 2 cohorts from HLA matched or mismatched donors. In both cohorts, the omitted group had a higher risk of severe acute and chronic GVHD. In conclusion, the omission of day 11 MTX was associated with a higher risk of severe GVHD. Therefore the omission of the day 11 dose is not recommended.
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Affiliation(s)
- Naokazu Nakamura
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fumiya Wada
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Hematology, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Kazunari Aoki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Stem Cell Genetics, Institute for Life and Medical Sciences, Kyoto University, Kyoto, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Department of Clinical Laboratory Medicine, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshio Kitawaki
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouhei Yamashita
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Buder K, Zirngibl M, Bapistella S, Meerpohl JJ, Strahm B, Bassler D, Weitz M. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in children and adolescents. Cochrane Database Syst Rev 2022; 6:CD009898. [PMID: 35679154 PMCID: PMC9181448 DOI: 10.1002/14651858.cd009898.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Chronic graft-versus-host disease (cGvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation, occurring in 6% to 65% of the paediatric recipients. Currently, the therapeutic mainstay for cGvHD is treatment with corticosteroids, frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory cGvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is the second update of a Cochrane Review first published in 2014 and first updated in 2015. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of cGvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (2021), MEDLINE (PubMed) and Embase databases from their inception to 25 January 2021. We searched the reference lists of potentially relevant studies without any language restrictions. We searched five conference proceedings and nine clinical trial registries on 9 November 2020 and 12 November 2020, respectively. SELECTION CRITERIA We aimed to include randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in children and adolescents with cGvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this 2021 review update. AUTHORS' CONCLUSIONS We could not evaluate the efficacy of ECP in the treatment of cGvHD in children and adolescents after haematopoietic stem cell transplantation since the second review update again found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this population will be challenging due to the limited number of eligible participants, variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, recipients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for children and adolescents treated with ECP.
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Affiliation(s)
- Kathrin Buder
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Matthias Zirngibl
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Sascha Bapistella
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
| | - Joerg J Meerpohl
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Brigitte Strahm
- Pediatric Hematology and Oncology Centre for Pediatrics and Adolescent Medicine, University Medical School Freiburg, Freiburg, Germany
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zürich, Zürich, Switzerland
| | - Marcus Weitz
- Department of General Paediatrics and Haematology/Oncology, University Hospital Tübingen, University Children's Hospital, Tübingen, Germany
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Ocular surface indicators and biomarkers in chronic ocular graft-versus-host disease: a prospective cohort study. Bone Marrow Transplant 2021; 56:1850-1858. [PMID: 33686249 PMCID: PMC8338548 DOI: 10.1038/s41409-021-01254-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 01/30/2021] [Accepted: 02/19/2021] [Indexed: 11/13/2022]
Abstract
This longitudinal cohort study compared ocular surface indicators in forty allogeneic hematopoietic stem cell transplant (HSCT) subjects with twenty healthy controls at baseline and identified changes in ocular graft-versus-host disease (oGVHD). Outcome measures included: Ocular Surface Disease Index (OSDI), tear osmolarity, Schirmer’s test, Oxford corneal staining score, tear break-up time (TBUT), and tear and serum biomarkers (IFN-γ, IL-10, MMP-9, IL-12, IL-13, IL-17α, IL-1β, IL-2, IL-4, IL-6, IL-8, CXCL10, MCP-1, MIP-1α, RANTES, TNF-α). At baseline the HSCT group had higher median Oxford corneal staining score (1.7 vs. 0.0; P < 0.0001), higher tear TNF-α (20.0 vs. 11.2 pg/mL; P < 0.0001), lower tear RANTES (70.4 vs. 190.2 pg/mL; P < 0.0001), higher serum IL-8 (10.2 vs. 4.5 pg/mL; P = 0.0008), and higher serum TNF-α (8.7 vs. 4.2 pg/mL; P < 0.0001). The incidence of oGVHD was 62% and associated changes included increased Oxford corneal staining score (4.6 vs. 1.8, P = 0.0001), decreased Schirmer’s test (3.0 vs. 10.0; P < 0.0001), and decreased TBUT (4.7 vs. 9.0 s; P = 0.0004). Baseline differences in ocular surface indicators suggest a tendency toward ocular dryness in individuals with hematologic disorders preparing for HSCT. Individuals who developed oGVHD showed changes in corneal staining score, Schirmer’s test, and TBUT.
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7
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Zarif-Yeganeh M, Kargar M. Comparison of the effect of different methods of cyclosporine infusion on transplant-related outcomes in allogeneic transplant recipients. J Oncol Pharm Pract 2021; 27:778-779. [PMID: 33626988 DOI: 10.1177/1078155221996761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Morvarid Zarif-Yeganeh
- Clinical Pharmacy Department, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Kargar
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
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Okoev G, Weisdorf DJ, Wagner JE, Blazar BR, MacMillan ML, DeFor T, Lazaryan A, El Jurdi N, Holtan SG, Brunstein CG, Betts BC, Takahashi T, Bachanova V, Warlick ED, Rashidi A, Arora M. Outcomes of chronic graft-versus-host disease following matched sibling donor versus umbilical cord blood transplant. Bone Marrow Transplant 2021; 56:1373-1380. [PMID: 33420387 DOI: 10.1038/s41409-020-01195-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/26/2020] [Accepted: 12/08/2020] [Indexed: 12/30/2022]
Abstract
We compared chronic graft-versus-host disease (cGvHD) following umbilical cord blood (UCBT) and matched sibling donor peripheral blood transplant (MSD). 145 patients (2010-2017) with cGvHD after MSD (n = 104) and UCBT (n = 41) were included. Prior acute GvHD was less frequent in MSD (55% vs. 85%; p = 0.01). Severe cGvHD (32% vs. 15%, p = 0.01) and de-novo onset (45% vs. 15%, p < 0.01) were more frequent following MSD. Liver was more frequently involved in MSD recipients (38% vs. 6%); and GI in UCBT (33% vs. 63%), both p < 0.01. Overall response (CR + PR) was similar between both cohorts. 2-year CR was higher in UCBT (14% vs 33%, p = 0.02). Karnofsky score (KPS) ≥ 90 at cGvHD diagnosis was associated with higher odds of response (95%CI: 1.42-10, p < 0.01). The cumulative incidence of durable discontinuation of immune-suppressive therapy, failure-free survival (FFS) and NRM at 2-years were similar between cohorts. KPS < 90 (95%CI: 3.1-24.9, p < 0.01) and platelets <100 × 10e9/L (95%CI: 1.25-10, p = 0.01) were associated with higher risk of NRM. UCBT patients were more likely to have a prior acute GvHD, less severe cGvHD and more likely to attain CR. Despite differences, both cohorts had similar NRM and FFS. High-risk groups, including those with platelets <100 × 10e9/L and KPS < 90, need careful monitoring and intensified therapy.
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Affiliation(s)
- Grigori Okoev
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA.
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - John E Wagner
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Bruce R Blazar
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Margaret L MacMillan
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Todd DeFor
- Division of Biostatistics, Clinical Translational Science Institute (CTSI), University of Minnesota, Minneapolis, MN, USA
| | - Aleksandr Lazaryan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Najla El Jurdi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Shernan G Holtan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Claudio G Brunstein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Brian C Betts
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Takuto Takahashi
- Department of Pediatrics, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Erica D Warlick
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Armin Rashidi
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
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Mohammed J, Kabir R, Bakhsh HR, Greenfield D, Georgievna VA, Bulińska A, Rai J, Gonzales A, Hashmi SK. Should healthcare organisations offer ongoing rehabilitation services for patients undergoing haematopoietic cell transplant? A narrative review. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2021. [DOI: 10.1108/ijhg-05-2020-0045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PurposeHematopoietic stem cell transplant (HSCT) patients can suffer from long-term transplant-related complications that affect their quality of life and daily activities. This study, a narrative review, aims to report the impact of HCT complications, the benefits of rehabilitation intervention, the need for long-term care and highlights the research gap in clinical trials involving rehabilitation.Design/methodology/approachA comprehensive search strategy was performed on several databases to look for relevant articles published from 1998 to 2018. Articles published in English with the following terms were used: hematopoietic stem cell transplant, chronic graft-versus-host disease, rehabilitation, exercise, physical therapy, occupational therapy. A patient/population, intervention, comparison, and outcomes (PICO) framework was employed to ensure that the search strategies were structured and precise. Study year, design, outcome, intervention, sample demographics, setting and study results were extracted.FindingsOf the 1,411 records identified, 51 studies underwent title/abstract screening for appropriateness, 30 were reviewed in full, and 19 studies were included in the review. The review found that, for the majority of patients who underwent HSCT and developed treatment-related complications, rehabilitation exercises had a positive impact on their overall quality of life. However, exercise prescription in this patient group has not always reflected the scientific approach; there is a lack of high-quality clinical trials in general. The review also highlights the need to educate healthcare policymakers and insurance companies responsible for rationing services to recognise the importance of offering long-term follow-up care for this patient group, including rehabilitation services.Practical implicationsA large number of HSCT patients require long-term follow-up from a multidisciplinary team, including rehabilitation specialists. It is important for healthcare policymakers and insurance companies to recognise this need and take the necessary steps to ensure that HSCT patients receive adequate long-term care. This paper also highlights the urgent need for high-quality rehabilitation trials to demonstrate the feasibility and importance of rehabilitation teams.Originality/valueHealthcare policymakers and insurance companies need to recognise that transplant patients need ongoing physiotherapy for early identification of any functional impairments and appropriate timely intervention.
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Zhu W, Feng YM, Chen T, Yao H, Quan Y, Rao J, Gao L, Zhang C, Liu Y, Gao L, Kong PY, Zhang X. [The clinical observation of sirolimus combined with calcineurin inhibitors for steroid-resistant/steroid-dependent extensive cGVHD]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:716-722. [PMID: 33113602 PMCID: PMC7595869 DOI: 10.3760/cma.j.issn.0253-2727.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Indexed: 11/05/2022]
Abstract
Objective: To observe the efficacy and safety of sirolimus combined with calcineurin inhibitor (CNI) in the treatment of glucocorticoid resistant/dependent extensive chronic graft-versus-host disease (cGVHD) . Methods: A total of 27 patients with steroid-resistant/steroid-dependent extensive cGVHD from November 2015 to January 2019 were enrolled and given sirolimus capsules combined with cyclosporine or tacrolimus to observe the clinical efficacy and adverse events. Results: The median duration of medication was 14.2 months and the mean duration was 16.7 months. The median follow-up time was 20.1 months (12.9-46.1 months) . Following the 6-month follow-up, 3 cases achieved complete response (CR) and 12 cases partial response (PR) . The overall response rate (ORR) was 55.6% ; for progression-free survival (PFS) , PFS-6 reached 88.9% (24/27) , and for overall survival (OS) , OS-6 was 100% . At the 1-year follow-up, there were 5 cases of CR and 11 cases of PR, ORR was 59.3% , PFS-12 reached 62.9% (17/27) , and OS-12 was 100% . The subgroup analysis found that the program was more effective for cGVHD in male donors and the target organ analysis had an advantage in the treatment of oral cavity, skin, and liver rejection. Adverse events were observed: hyperlipidemia 11.1% , oral ulcer 7.4% , fungal infection 11.1% , liver injury 3.7% , renal insufficiency 0, and no new CMV and EB viremia. Conclusion: Sirolimus combined with calcineurin inhibitors is effective in treating steroid-resistant/steroid-dependent extensive cGVHD, especially because adverse reactions (renal toxicity, CMV, EBV infection) are low in number, which is suitable for long-term treatment of cGVHD.
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Affiliation(s)
- W Zhu
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - Y M Feng
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - T Chen
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - H Yao
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - Y Quan
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - J Rao
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - L Gao
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - C Zhang
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - Y Liu
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - L Gao
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - P Y Kong
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
| | - X Zhang
- Medical Center of Hematology, Xinqiao Hospital of Army Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, PLA Blood Disease Center, Chongqing Key Discipline of Medicine, Chongqing 400037, China
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11
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Wang B, Liang Z, Liu W, Sun Y, Cen X, Dong Y, Ren H. The predictive value of serum free light chain level early after allogeneic hematopoietic stem cell transplantation for chronic graft-versus-host disease, a preliminary study. Clin Transplant 2020; 34:e13865. [PMID: 32242991 DOI: 10.1111/ctr.13865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/02/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Serum free light chain (FLC) level is closely associated with the functional state of B lymphocytes, and many studies have shown that delayed reconstitution of B lymphocytes contributed to chronic graft-versus-host disease (cGVHD). This study assessed the predictive value of FLC levels in serum collected early after allogeneic hematopoietic stem cell transplantation (allo-HSCT) for cGVHD. METHODS Sixty-two patients who had undergone allo-HSCT were retrospectively reviewed. The correlations between the FLC levels and the development of cGVHD were explored. RESULTS Of the 62 patients, 33 cases developed cGVHD, with the prevalence of 53.2%. With Seattle classification, 19 cases had limited cGVHD while 14 cases contracted extensive cGVHD. While with NIH classification, 17 cases had mild cGVHD, 6 cases moderate cGVHD, and 10 cases severe cGVHD. Multivariant statistical analysis showed that the FLC levels were not associated with all severities of cGVHD but were correlated with the development of extensive or moderate to severe cGVHD (P = .01 and .038, respectively). CONCLUSIONS Serum FLC levels early after HSCT may reflect the functional state of B-cell reconstitution. Patients with low serum FLC Level early post-allo-HSCT tend to develop extensive cGVHD or moderate to severe cGVHD.
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Affiliation(s)
- Bingjie Wang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Zeyin Liang
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Wei Liu
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Yuhua Sun
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Xi'nan Cen
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Yujun Dong
- Department of Hematology, Peking University First Hospital, Beijing, China
| | - Hanyun Ren
- Department of Hematology, Peking University First Hospital, Beijing, China
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12
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13
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A case of central nervous system graft-versus-host disease following allogeneic stem cell transplantation. Int J Hematol 2019; 110:635-639. [PMID: 31309419 DOI: 10.1007/s12185-019-02702-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/01/2019] [Accepted: 07/04/2019] [Indexed: 12/27/2022]
Abstract
Graft-versus-host disease (GVHD) is a serious complication of allogeneic stem cell transplantation (SCT). Here, we report a rare case of GVHD involving the central nervous system (CNS). A 35-year-old woman was diagnosed with myelodysplastic syndrome unclassifiable and underwent allogeneic peripheral blood SCT for disease progression to myelodysplastic syndrome with excess blasts-2. One year following SCT, she experienced chronic oral and hepatic GVHD symptoms, which were managed with oral steroids and tacrolimus. Sixteen months after SCT, she developed sudden-onset, generalized, tonic-clonic-type seizures. Magnetic resonance imaging and cerebrospinal fluid evaluation showed multiple discrete white lesions and elevated IgG levels. Brain biopsy revealed periventricular plaques with the destruction of axons, representing a demyelinating disease of the CNS. We diagnosed the case as CNS GVHD. Neurologic symptoms gradually improved with methylprednisolone pulse therapy and total plasma exchange combined with a calcineurin inhibitor; the brain lesions nearly disappeared after decreasing steroid maintenance dosage, and were completely resolved 1 year after the onset of CNS GVHD. The patient is CNS GVHD-symptom-free, 3-year post-transplantation. Thus, CNS GVHD should be considered in cases of newly developed neurologic symptoms in SCT recipients showing evidence of preceding chronic GVHD.
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14
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Kanagasundram S, Amini F. Late Complications of Allogenic Stem Cells Transplantation in Leukaemia. Tissue Eng Regen Med 2019; 16:1-9. [PMID: 30815345 PMCID: PMC6361097 DOI: 10.1007/s13770-018-0157-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/16/2018] [Accepted: 08/13/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) can cure leukaemia. However, long term complications of post transplantation interfere with the patients' full recovery. The objective of this review was to identify the various long term complications and to assess their individual prevalences. METHODS Electronic databases including PubMed, Google Scholar and Cochrane were searched for years 2004-2017. The keywords used were leukaemia, allogenic stem cell transplantation, prevalence, side effects, long term, delayed, adverse effects, complications and outcome. RESULTS A total of ten articles were included for analysis. There were 5 prospective studies, 3 retrospective studies and 2 cross sectional studies. A total of 40,069 patients, (20,189 males and 17,191 females) participated in these 10 studies. The gender of 2689 patients were not disclosed. Most common late complications and prevalence were chronic graft versus host disease (43% at 5 years post HSCT), secondary tumor (21% at 20 years post HSCT), hypothyroidism (11% at 15 years), bronchiolitis obliterans (9.7% at 122 days), cardiovascular disease (7.5% at 15 years) and avascular necrosis (5.4% at 10 years). The prevalence of azoospermia was 71.1% and depression, 18%. For the latter two conditions no time limit was available. Follow up duration ranged from 2 years till 30 years post HSCT. CONCLUSION While allogenic stem cell transplantation is an effective cure for leukaemia, the procedure is associated with complications that can have their onset many years after the procedure.
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Affiliation(s)
- Sharmilla Kanagasundram
- Department of Psychological Medicine, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur, Malaysia
| | - Farhanaz Amini
- School of Healthy Aging, Medical Aesthetics and Regenerative Medicine, University College Sedaya International (UCSI), Jalan Menara Gading 1, Taman Connaught, 56000 Kuala Lumpur, Selangor Malaysia
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15
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de Greef GE, Braakman E, van der Holt B, Janssen JJWM, Petersen E, Vucinic V, Thuss N, Grootes M, Cornelissen JJ. The feasibility and efficacy of subcutaneous plerixafor for mobilization of peripheral blood stem cells in allogeneic HLA-identical sibling donors: results of the HOVON-107 study. Transfusion 2018; 59:316-324. [PMID: 30548284 PMCID: PMC7380058 DOI: 10.1111/trf.15037] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 08/31/2018] [Accepted: 08/31/2018] [Indexed: 12/25/2022]
Abstract
Background Plerixafor (PFX) mobilizes CD34+ cells into circulation by disrupting the CXCR4 binding of the hematopoietic stem cell in its bone marrow niche. Study design and Methods in the prospective HOVON‐107 study (www.hovon.nl) 23 allogeneic HLA–identical sibling donors received one or two subcutaneous (sc) injections of plerixafor 0.320 mg/kg.The primary endpoint, was defined as feasibility to mobilize a minimum of 2.0 x106 CD34+ cells/kg recipient weight obtained by leukopheresis in at least 90% of the donors. Results median 3.3 x 106 CD34+ cells/kg (1.9‐6.5) were collected after 1 (n=12) or 2 (n=10) sc injections of PFX. Side effects occurred in 15/23 (65%) donors: most were grade 1‐2; in 5 donors grade 3 and all resolved. All grafts were directly transplanted. Compared to 10 grafts obtained with G‐CSF the number of CD34+ cells was 2.4 fold lower but the percentage of phenotypically most immature CD34+ subset was higher (31% vs 15%). The total number of CD3+ cells in the graft seemed higher after PFX‐mobilization, but CD4/CD 8 ratios, and frequencies of Th2, Th17 and regulatory T‐cells or NK cells were comparable. All patients engrafted and no increase in incidence or severity of acute or chronic graft versus host disease was observed. Conclusion stem cell mobilization with sc PFX 0.320 mg/kg in allogeneic sibling donors is feasible with limited toxicity for donors. 14 allogeneic donors were mobilized with PFX 0.320 mg intravenously according to the same protocol. Due to the limited numbers, these results are in the supplementary section.
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Affiliation(s)
- Georgine E de Greef
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Eric Braakman
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Bronno van der Holt
- Department of Hematology, HOVON Data Center. Erasmus MC, Rotterdam, Netherlands
| | | | - Eefke Petersen
- Department of Hematology, UMC Utrecht, Utrecht, Netherlands
| | - Vladimir Vucinic
- Department of Hematology, Clinical Oncology and Hemostaseology, University of Leipzig, Leipzig, Germany
| | - Nicole Thuss
- Department of Hematology, HOVON Data Center. Erasmus MC, Rotterdam, Netherlands
| | - Meriam Grootes
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
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16
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Solomon SR, Sizemore CA, Ridgeway M, Zhang X, Brown S, Holland HK, Morris LE, Solh M, Bashey A. Safety and efficacy of rituximab-based first line treatment of chronic GVHD. Bone Marrow Transplant 2018; 54:1218-1226. [PMID: 30518977 DOI: 10.1038/s41409-018-0399-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 09/22/2018] [Accepted: 11/08/2018] [Indexed: 11/09/2022]
Abstract
Initial therapy of chronic GVHD (cGvHD) has not changed for over three decades, despite limited efficacy and long-term toxicity. We have previously shown in a small pilot study the feasibility of rituximab-based first-line therapy of cGVHD. To better assess safety and efficacy, we now evaluate 69 patients that received rituximab as part of their initial treatment. Median follow-up for surviving patients was 47 (11-81) months. Resolution of cGVHD occurred in 49 patients with median time to IST discontinuation of 349 (138-920) days. The cumulative incidence (CI) of cGHVD resolution was 41%, 69 and 77% at 1-, 2- and 3-years, respectively. No systemic corticosteroids were used in 27 patients, and 67% received ≤ 10 mg/kg cumulative exposure. Overall survival (OS) at 1-, 2- and 3-years following cGVHD diagnosis was 87, 79 and 77% respectively; corresponding rates of non-relapse mortality (NRM) were 10%, 16 and 19%. The probability of being alive and free of cGVHD at 1-, 2-, and 3-years was 36, 55, and 57% respectively. This study demonstrates the feasibility and efficacy of rituximab-based first-line cGVHD treatment. This approach demonstrates significant activity and avoids long courses of corticosteroids in most patients.
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Affiliation(s)
- Scott R Solomon
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA.
| | - Connie A Sizemore
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Michelle Ridgeway
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Xu Zhang
- The University of Texas, Health Science Center at Houston, Houston, TX, USA
| | - Stacey Brown
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - H Kent Holland
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Lawrence E Morris
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Melhem Solh
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Asad Bashey
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
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17
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Mawardi H, Hashmi SK, Elad S, Aljurf M, Treister N. Chronic graft‐versus‐host disease: Current management paradigm and future perspectives. Oral Dis 2018; 25:931-948. [DOI: 10.1111/odi.12936] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/04/2018] [Accepted: 07/04/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Hani Mawardi
- Faculty of Dentistry King AbdulAziz University Jeddah Kingdom of Saudi Arabia
- AlFarabi Private College Jeddah Kingdom of Saudi Arabia
| | - Shahrukh K. Hashmi
- Department of Medicine Mayo Clinic Rochester Minnesota
- Oncology Center KFSHRC Riyadh Kingdom of Saudi Arabia
| | - Sharon Elad
- Department of Dentistry University of Rochester Rochester New York
| | | | - Nathaniel Treister
- Division of Oral Medicine and Dentistry, Brigham and Women's Hospital Boston Massachusetts
- Department of Oral Medicine, Infection and Immunity Harvard School of Dental Medicine Boston Massachusetts
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18
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Ferreli C, Gasparini G, Parodi A, Cozzani E, Rongioletti F, Atzori L. Cutaneous Manifestations of Scleroderma and Scleroderma-Like Disorders: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:306-336. [PMID: 28712039 DOI: 10.1007/s12016-017-8625-4] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Scleroderma refers to an autoimmune connective tissue fibrosing disease, including three different subsets: localized scleroderma, limited cutaneous systemic sclerosis, and diffuse cutaneous systemic sclerosis with divergent patterns of organ involvement, autoantibody profiles, management, and prognostic implications. Although systemic sclerosis is considered the disease prototype that causes cutaneous sclerosis, there are many other conditions that can mimic and be confused with SSc. They can be classified into immune-mediated/inflammatory, immune-mediated/inflammatory with abnormal deposit (mucinoses), genetic, drug-induced and toxic, metabolic, panniculitis/vascular, and (para)neoplastic disorders according to clinico-pathological and pathogenetic correlations. This article reviews the clinical presentation with emphasis on cutaneous disease, etiopathogenesis, diagnosis, and treatment options available for the different forms of scleroderma firstly and for scleroderma-like disorders, including scleromyxedema, scleredema, nephrogenic systemic fibrosis, eosinophilic fasciitis, chronic graft-versus-host disease, porphyria cutanea tarda, diabetic stiff-hand syndrome (diabetic cheiroartropathy), and other minor forms. This latter group of conditions, termed also scleroderma mimics, sclerodermiform diseases, or pseudosclerodermas, shares the common thread of skin thickening but presents with distinct cutaneous manifestations, skin histology, and systemic implications or disease associations, differentiating each entity from the others and from scleroderma. The lack of Raynaud's phenomenon, capillaroscopic abnormalities, or scleroderma-specific autoantibodies is also important diagnostic clues. As cutaneous involvement is the earliest, most frequent and characteristic manifestation of scleroderma and sclerodermoid disorders, dermatologists are often the first-line doctors who must be able to promptly recognize skin symptoms to provide the affected patient a correct diagnosis and appropriate management.
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Affiliation(s)
- Caterina Ferreli
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| | - Giulia Gasparini
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Aurora Parodi
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Emanuele Cozzani
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Franco Rongioletti
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Laura Atzori
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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19
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Adachi Y, Ukai S, Sagou K, Fukushima N, Ozeki K, Kohno A. Promising Outcome of Umbilical Cord Blood Transplantation in Patients with Multiple Comorbidities. Biol Blood Marrow Transplant 2018; 24:1455-1462. [DOI: 10.1016/j.bbmt.2018.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/10/2018] [Indexed: 01/08/2023]
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20
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Full-body physical therapy evaluation for pre- and post-hematopoietic cell transplant patients and the need for a modified rehabilitation musculoskeletal specific grading system for chronic graft-versus-host disease. Bone Marrow Transplant 2018; 53:625-627. [PMID: 29348574 DOI: 10.1038/s41409-017-0075-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/12/2017] [Accepted: 12/03/2017] [Indexed: 11/09/2022]
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21
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Leung J, Smith S, Kalpakjian C. Functional Outcomes of Acute Inpatient Rehabilitation in Patients With Chronic Graft-Versus-Host Disease. PM R 2017; 10:567-572. [PMID: 29141183 DOI: 10.1016/j.pmrj.2017.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Growing numbers of allogeneic stem cell transplants and improved posttransplant care have led to an increase of individuals with chronic graft-versus-host disease (cGVHD). Although cGVHD leads to functional impairment for many, there is limited literature regarding the benefits of acute inpatient rehabilitation for patients with cGVHD. OBJECTIVE To assess Functional Independence Measure (FIM) outcomes of patients with cGVHD during acute inpatient rehabilitation and to compare inpatient rehabilitation outcomes with patients with burn injuries, a rehabilitation patient population with similar comorbidities. DESIGN Retrospective chart review. SETTING Acute rehabilitation center at a large academic medical center. PATIENTS (OR PARTICIPANTS) A total of 37 adult patients with cGVHD and 30 with burn injuries admitted to inpatient rehabilitation from 2010 to 2015. METHODS OR INTERVENTIONS Linear regression analysis to evaluate group (cGVHD versus burn) differences in functional gains. Effect size and minimal detectable change at the 90% confidence level (MDC90) were used to evaluate change in FIM outcomes. MAIN OUTCOME MEASUREMENTS Total FIM gain, motor FIM gain, and FIM efficiency. RESULTS Patients with cGVHD had statistically significant lower functional gains than patients with burn injuries, with an average of 11.66 fewer total FIM points (P ≤ .001), 10.54 fewer motor FIM points (P = .01), and 2.45 units less of FIM efficiency (P = .01). At the time of discharge, 7 (18%) patients with cGVHD exceeded the MDC90 values for total FIM gain versus 9 (30%) patients with burn injuries (P = .26). Eight (21%) patients with cGVHD exceeded the MDC90 for motor FIM gain versus 13 (43%) patients with burn injuries (P = .048). Effect sizes for patients with cGVHD and with burn injury were moderate to large, respectively, with patients with burn injuries having nearly twice the magnitude of gains as patients with cGVHD. CONCLUSIONS Despite achieving more modest functional gains than patients with burn injuries, patients with cGVHD improved in function after acute inpatient rehabilitation. If replicated in larger studies, patients with functional impairment from cGVHD can be considered for inpatient rehabilitation. Future work should also determine minimal clinically important differences in function gain from inpatient rehabilitation for patients with cGVHD. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Jason Leung
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, 325 E. Eisenhower Parkway, Suite 200, Ann Arbor, MI 48108
| | - Sean Smith
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, 325 E. Eisenhower Parkway, Suite 200, Ann Arbor, MI 48108
| | - Claire Kalpakjian
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, MI
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, 325 E. Eisenhower Parkway, Suite 200, Ann Arbor, MI 48108
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22
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Solomon SR, Sizemore C, Zhang X, Ridgeway M, Solh M, Morris LE, Holland HK, Bashey A. Current Graft-versus-Host Disease–Free, Relapse-Free Survival: A Dynamic Endpoint to Better Define Efficacy after Allogenic Transplant. Biol Blood Marrow Transplant 2017; 23:1208-1214. [DOI: 10.1016/j.bbmt.2017.02.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/22/2017] [Indexed: 11/26/2022]
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23
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Bohmann EM, Fehn U, Holler B, Weber D, Holler E, Herr W, Hoffmann P, Edinger M, Wolff D. Altered immune reconstitution of B and T cells precedes the onset of clinical symptoms of chronic graft-versus-host disease and is influenced by the type of onset. Ann Hematol 2016; 96:299-310. [PMID: 27942862 DOI: 10.1007/s00277-016-2881-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Abstract
We analyzed lymphocyte subpopulations and cytokines 3 months after allogeneic hematopoietic stem cell transplantation aiming to identify predictive cellular and serum markers for chronic graft-versus-host disease (cGVHD). Samples of 49 patients (pts) (no cGVHD (n = 14), subsequent quiescent onset (n = 16), de novo onset of cGVHD (n = 19)) were analyzed in the absence of active GVHD by flow cytometry and enzyme-linked immunosorbent assay. All mean absolute cell counts are presented as cells per microliter; relative cell counts are presented as percentage of lymphocytes. Pts with subsequent de novo cGVHD had significantly higher relative and absolute counts of CD4+ T cells including higher absolute counts of CD4+ memory T cells (22.36%; 206.55/μl; 136/μl, respectively) compared to pts with subsequent quiescent onset of cGVHD (12.41%; 83.42/μl; 54.3/μl) and pts without cGVHD (10.55%) with regard to relative counts of CD4+ T cells. Similarly, significantly more relative and absolute regulatory T cell numbers (CD4+FOXP3+) were detected in pts with de novo onset of cGVHD (3.08% and 24.63/μl) compared to those in pts without (1.25% and 9.06/μl) or with quiescent onset of cGVHD (1.15% and 6.91/μl). Finally, relative B cell counts, including naïve and memory B cells, were also significantly decreased in pts developing quiescent cGVHD (0.85, 0.73, 0.12% resp.) when compared to pts with de novo onset (5.61, 5.24, 0.38%). The results demonstrate that alterations in immune reconstitution are already present before onset of clinical symptoms and differ between de novo and quiescent onset of disease.
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Affiliation(s)
- E-M Bohmann
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - U Fehn
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - B Holler
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - D Weber
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - E Holler
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - W Herr
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany
| | - P Hoffmann
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - M Edinger
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany.,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - D Wolff
- Department of Internal Medicine III, University Hospital of Regensburg, F.J. Strauss Allee 11, 93053, Regensburg, Germany. .,Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany.
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24
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Abstract
Hematopoietic stem cell transplantation is important in the management of several lymphoproliferative and bone marrow disorders. Graft-versus-host disease (GVHD) involves inflammatory manifestations that arise after transplant and can affect many organs. Ocular manifestations of GVHD are common, and eye care providers must understand this disease entity. The ocular surface is most commonly involved, but GVHD can affect all parts of the eye. Ocular GVHD can be relapsing and remitting, can decrease quality of life, and can be challenging to diagnose and adequately treat. The diagnostic criteria for and grading of ocular GVHD continue to evolve. This review aims to summarize current definitions, clinical findings, diagnostic criteria, and management of ocular GVHD. The care of patients with ocular GVHD requires a multidisciplinary approach.
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25
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Punatar S, Gupta A, Gawande J, Bagal B, Mathew L, Kannan S, Khattry N. Chronic Graft Versus Host Disease in Acute Leukemia Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplant: Analysis of Risk Factors, Pattern and Long Term Outcome. Indian J Hematol Blood Transfus 2016; 32:32-8. [PMID: 26855504 PMCID: PMC4733673 DOI: 10.1007/s12288-015-0506-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/09/2015] [Indexed: 11/30/2022] Open
Abstract
Chronic graft versus host disease (cGVHD) is a common late complication of allogenic hematopoietic stem cell transplant (HSCT). We analyzed risk factors, pattern and long term transplant outcomes of cGVHD at a tertiary cancer centre. Seventy-seven consecutive patients who underwent HSCT for acute leukemia were included. Forty (52 %) patients developed cGVHD; 24 (60 %) extensive stage while 16 (40 %) limited stage. Oral cavity was the commonest site of involvement (25 patients) followed by liver, skin and lung. We found that female donor to male recipient transplant and diagnosis of acute lymphoblastic leukemia (ALL) were the only factors associated with increased risk of cGVHD. The incidence of leukemia relapse was 18 % in patients who developed cGVHD compared to 51 % in those who did not (P = 0.002). Four year overall survival and relapse free survival (RFS) were 62 and 46 % in patients who developed cGVHD compared to 29 % (P < 0.001) and 29 % (P < 0.001) in patients who did not develop cGVHD, respectively. We conclude that cGVHD is more common in male patients with female donors and in patients transplanted for ALL. Oral cavity is the commonest site of cGVHD in our patients and transplant related survival outcomes are superior in patients who develop cGVHD.
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Affiliation(s)
- Sachin Punatar
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Mumbai, 410210 India
| | - Alok Gupta
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Mumbai, 410210 India
| | - Jayant Gawande
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Mumbai, 410210 India
| | - Bhausaheb Bagal
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Mumbai, 410210 India
| | - Libin Mathew
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Mumbai, 410210 India
| | - Sadhana Kannan
- />Department of Biostatistics, ACTREC, Tata Memorial Centre, Mumbai, 410210 India
| | - Navin Khattry
- />Bone Marrow Transplant Unit, Department of Medical Oncology, ACTREC, Tata Memorial Centre, Mumbai, 410210 India
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Weitz M, Strahm B, Meerpohl JJ, Schmidt M, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2015; 2015:CD009898. [PMID: 26666581 PMCID: PMC7093760 DOI: 10.1002/14651858.cd009898.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options for these patients include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. This is an updated version of a Cochrane review first published in 2014. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL) (Issue 9, 2015), MEDLINE and EMBASE databases from their inception to 23 September 2015. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings on 29 September 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS No additional studies were identified in this 2015 review update, in total leading to no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs cannot be evaluated since the original version of this review and the first review update found no RCTs. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical data are made in favour of ECP, patients should be carefully monitored for beneficial and harmful effects. In addition, efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Brigitte Strahm
- University Medical School FreiburgPediatric Hematology and Oncology Centre for Pediatrics and Adolescent MedicineMathildenstrasse 1FreiburgGermany79106
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBerliner Allee 29FreiburgGermany79110
| | - Maria Schmidt
- University Children's HospitalPediatric NephrologySteinwiesstrasse 75ZurichSwitzerland8032
| | - Dirk Bassler
- University Hospital ZurichDepartment of NeonatologyFrauenklinikstrasse 10ZurichSwitzerland
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Solomon SR, Sizemore CA, Ridgeway M, Zhang X, Smith J, Brown S, Holland HK, Morris LE, Bashey A. Corticosteroid-Free Primary Treatment of Chronic Extensive Graft-versus-Host Disease Incorporating Rituximab. Biol Blood Marrow Transplant 2015; 21:1576-82. [DOI: 10.1016/j.bbmt.2015.04.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 04/27/2015] [Indexed: 11/17/2022]
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Epidermal elafin expression is an indicator of poor prognosis in cutaneous graft-versus-host disease. J Invest Dermatol 2014; 135:999-1006. [PMID: 25405322 DOI: 10.1038/jid.2014.489] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 11/04/2014] [Accepted: 11/05/2014] [Indexed: 11/09/2022]
Abstract
Graft-versus-host disease (GVHD) remains a common and potentially life-threatening complication of allogeneic hematopoietic stem cell transplantation. In the skin, GVHD can present in an acute (aGVHD), chronic lichenoid (clGVHD), or chronic sclerotic form (csGVHD). Measuring peripheral blood levels of the keratinocyte-derived protease inhibitor elafin has recently emerged as a promising tool for the diagnosis of cutaneous aGVHD. We evaluated whether the analysis of elafin expression in skin would allow distinguishing aGVHD from drug hypersensitivity rashes (DHR) and whether cutaneous elafin expression would correlate with disease severity or altered prognosis of aGVHD and clGVHD/csGVHD. Skin biopsies from aGVHD (n=22), clGVHD (n=15), csGVHD (n=7), and DHR (n=10) patients were collected and epidermal elafin expression and its association with diverse clinical/histological parameters were analyzed. Acute GVHD and DHR displayed varying degrees of elafin expression. No elafin was detectable in csGVHD, whereas the molecule was increased in clGVHD as compared with aGVHD. Elafin-high aGVHD/clGVHD lesions presented with epidermal thickening and were associated with poor prognosis-i.e., decreased overall survival in aGVHD and corticosteroid resistance in clGVHD. Although cutaneous elafin does not seem to discriminate aGVHD from DHR lesions, our study strongly suggests an association between cutaneous elafin expression and poor prognosis for patients with cutaneous GVHD.
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Andani R, Robertson I, Macdonald KPA, Durrant S, Hill GR, Khosrotehrani K. Origin of Langerhans cells in normal skin and chronic GVHD after hematopoietic stem-cell transplantation. Exp Dermatol 2014; 23:75-7. [PMID: 24313654 DOI: 10.1111/exd.12301] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2013] [Indexed: 12/28/2022]
Abstract
Chronic graft-versus-host disease (cGVHD) is a common complication following allogeneic stem-cell transplantation (SCT). Past studies have implicated the persistence of host antigen-presenting cells (APCs) in GVHD. Our objective was to determine the frequency of host Langerhans cells (LCs) in normal skin post-SCT and ask if their persistence could predict cGVHD. Biopsies of normal skin from 124 sex-mismatched T-cell-replete allogenic SCT recipients were taken 100 days post-transplant. Patients with acute GVHD and those with <9 months of follow-up were excluded and prospective follow-up information was collected from remaining 22 patients. CD1a staining and X and Y chromosome in-situ hybridization were performed to label LCs and to identify their host or donor origin. At 3 months, 59 ± 5% of LCs were host derived. The density of LCs and the proportion of host-derived LCs were similar between patients that did or did not develop cGVHD. Most LCs in the skin remained of host origin 3 months after SCT regardless of cGVHD status. This finding is in line with the redundant role of LCs in acute GVHD initiation uncovered in recent experimental models.
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Affiliation(s)
- Rafiq Andani
- Experimental Dermatology Laboratory, UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
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Knobler R, Berlin G, Calzavara-Pinton P, Greinix H, Jaksch P, Laroche L, Ludvigsson J, Quaglino P, Reinisch W, Scarisbrick J, Schwarz T, Wolf P, Arenberger P, Assaf C, Bagot M, Barr M, Bohbot A, Bruckner-Tuderman L, Dreno B, Enk A, French L, Gniadecki R, Gollnick H, Hertl M, Jantschitsch C, Jung A, Just U, Klemke CD, Lippert U, Luger T, Papadavid E, Pehamberger H, Ranki A, Stadler R, Sterry W, Wolf IH, Worm M, Zic J, Zouboulis CC, Hillen U. Guidelines on the use of extracorporeal photopheresis. J Eur Acad Dermatol Venereol 2014; 28 Suppl 1:1-37. [PMID: 24354653 PMCID: PMC4291097 DOI: 10.1111/jdv.12311] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 01/10/2023]
Abstract
BACKGROUND After the first investigational study on the use of extracorporeal photopheresis for the treatment of cutaneous T-cell lymphoma was published in 1983 with its subsequent recognition by the FDA for its refractory forms, the technology has shown significant promise in the treatment of other severe and refractory conditions in a multi-disciplinary setting. Among the major studied conditions are graft versus host disease after allogeneic bone marrow transplantation, systemic sclerosis, solid organ transplant rejection and inflammatory bowel disease. MATERIALS AND METHODS In order to provide recognized expert practical guidelines for the use of this technology for all indications the European Dermatology Forum (EDF) proceeded to address these questions in the hands of the recognized experts within and outside the field of dermatology. This was done using the recognized and approved guidelines of EDF for this task. RESULTS AND CONCLUSION These guidelines provide at present the most comprehensive available expert recommendations for the use of extracorporeal photopheresis based on the available published literature and expert consensus opinion.
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Affiliation(s)
- R Knobler
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
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Weitz M, Strahm B, Meerpohl JJ, Bassler D. Extracorporeal photopheresis versus alternative treatment for chronic graft-versus-host disease after haematopoietic stem cell transplantation in paediatric patients. Cochrane Database Syst Rev 2014:CD009898. [PMID: 24569961 DOI: 10.1002/14651858.cd009898.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Chronic graft-versus-host disease (GvHD) is a major cause of morbidity and mortality after haematopoietic stem cell transplantation occurring in 6% to 65% of the recipients. Currently, the therapeutic mainstay for chronic GvHD are corticosteroids that are frequently combined with other immunosuppressive agents in people with steroid-refractory manifestations. There is no established standard treatment for steroid-refractory chronic GvHD. The therapeutic options in these people include extracorporeal photopheresis (ECP), an immunomodulatory treatment that involves ex vivo collection of mononuclear cells from peripheral blood, exposure to the photoactive agent 8-methoxypsoralen, ultraviolet radiation and re-infusion of the processed cell product. The mechanisms of action of ECP are not completely understood. OBJECTIVES To evaluate the effectiveness and safety of ECP for the management of chronic GvHD in children and adolescents after haematopoietic stem cell transplantation. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (Issue 9, 2012), MEDLINE and EMBASE databases from their inception to 12 September 2012. We searched the reference lists of potentially relevant studies without any language restriction. We searched eight trial registers and five conference proceedings. We also contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing ECP with or without alternative treatment versus alternative treatment alone in paediatric patients with chronic GvHD after haematopoietic stem cell transplantation. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. We resolved disagreements in the selection of trials by consultation with a third review author. MAIN RESULTS We found no studies meeting the criteria for inclusion in this review. AUTHORS' CONCLUSIONS The efficacy of ECP in the treatment of chronic GvHD in paediatric patients after haematopoietic stem cell transplantation based on RCTs can currently not be evaluated since we have found no such studies. Current recommendations are based on retrospective or observational studies only. Thus, ideally, ECP should be applied in the context of controlled trials only. However, performing RCTs in this patient population will be challenging due to the limited number of patients, the variable disease presentation and the lack of well-defined response criteria. International collaboration, multicentre trials and appropriate funding for such trials will be needed. If treatment decisions based on clinical grounds in favour of ECP are made, people should be carefully monitored for beneficial and harmful effects and efforts should be made to share this information with other clinicians, for example by setting up registries for paediatric patients that are treated with ECP.
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Affiliation(s)
- Marcus Weitz
- Department of Pediatrics, University of Tuebingen, Hoppe-Seyler-Strasse 1, Tübingen, Germany, 72076
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32
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Diverse T-cell responses characterize the different manifestations of cutaneous graft-versus-host disease. Blood 2013; 123:290-9. [PMID: 24255916 DOI: 10.1182/blood-2013-07-514372] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic stem cell transplantation (HCT) and can present in an acute (aGVHD), a chronic lichenoid (clGVHD), and a chronic sclerotic form (csGVHD). It is unclear whether similar or different pathomechanisms lead to these distinct clinical presentations. To address this issue, we collected lesional skin biopsies from aGVHD (n = 25), clGVHD (n = 17), and csGVHD (n = 7) patients as well as serial nonlesional biopsies from HCT recipients (prior to or post-HCT) (n = 14) and subjected them to phenotypic and functional analyses. Our results revealed striking differences between aGVHD and clGVHD. In aGVHD, we found a clear predominance of T helper (Th)2 cytokines/chemokines and, surprisingly, of interleukin (IL)-22 messenger RNA as well as an increase of IL-22-producing CD4(+) T cells. Thymic stromal lymphopoietin, a cytokine skewing the immune response toward a Th2 direction, was elevated at day 20 to 30 post-HCT in the skin of patients who later developed aGVHD. In sharp contrast to aGVHD, the immune response occurring in clGVHD showed a mixed Th1/Th17 signature with upregulated Th1/Th17 cytokine/chemokine transcripts and elevated numbers of interferon-γ- and IL-17-producing CD8(+) T cells. Our findings shed new light on the T-cell responses involved in the different manifestations of cutaneous GVHD and identify molecular signatures indicating the development of the disease.
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Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has evolved over the past two decades to become the standard of care for hematologic and lymphoid malignancies. Major ocular complications after allogeneic HSCT have been increasing in number and severity. Graft-versus-host disease (GVHD) remains a major cause of ocular morbidity after allogeneic HSCT. The main objective of this review is to elucidate the ocular complications in patients developing GVHD following HSCT. Ocular complications secondary to GVHD are common and include dry eye syndrome, acquisition of ocular allergy from donors with allergic disorders. Eyelid changes may occur in GVHD leading to scleroderma-like changes. Patients may develop poliosis, madarosis, vitiligo, lagophthalmos, and entropion. The cornea may show filamentary keratitis, superficial punctate keratitis, corneal ulcers, and peripheral corneal melting which may lead to perforation in severe cases. Scleritis may also occur which can be anterior or posterior. Keratoconjunctivis sicca appears to be the most common presentation of GVHD. The lacrimal glands may be involved with mononuclear cell infiltration of both the major and accessory lacrimal glands and decrease in tear production. Severe dry eye syndrome in patients with GVHD may develop conjunctival scarring, keratinization, and cicatrization of the conjunctiva. Therapy of GVHD includes systemic immunosuppression and local therapy. Surgical treatment in refractory cases includes surgical intervention to improve the manifestation of GVHD of the eye. This may include tarsorrhapy, prose lenses, punctal occlusions and corneal transplantation.
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Affiliation(s)
- Amr Nassar
- Adult Hematology/HSCT, King Faisal Cancer Center, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Khalid F. Tabbara
- The Eye Center and The Eye Foundation for Research in Ophthalmology, Riyadh, Saudi Arabia
| | - Mahmoud Aljurf
- Research Center, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Shikari H, Antin JH, Dana R. Ocular Graft-versus-Host Disease: A Review. Surv Ophthalmol 2013; 58:233-51. [DOI: 10.1016/j.survophthal.2012.08.004] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 07/30/2012] [Accepted: 08/07/2012] [Indexed: 12/13/2022]
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Donor-derived regulatory B cells are important for suppression of murine sclerodermatous chronic graft-versus-host disease. Blood 2013; 121:3274-83. [PMID: 23422748 DOI: 10.1182/blood-2012-11-465658] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Chronic graft-versus-host disease (cGVHD) is an increasingly frequent cause of morbidity and mortality of allogeneic hematopoietic stem-cell transplantation. Sclerodermatous cGVHD (Scl-cGVHD) is characterized by fibrosis and autoimmune features resembling those of systemic sclerosis (SSc). Transplantation of B10.D2 bone marrow and splenocytes into irradiated BALB/c mice is an established model of human Scl-cGVHD. To examine the role of B cells in Scl-cGVHD, CD19-deficient (CD19(-/-)) mice were used as donors or recipients. CD19(-/-) donors induced more severe Scl-cGVHD than wild-type donors, but use of CD19(-/-) recipients resulted in no significant differences compared with wild-type recipients. Moreover, CD19 deficiency on donor B cells resulted in the expansion of splenic interleukin (IL) -6-producing monocytes/macrophages, cytotoxic CD8(+) T cells, and Th1 cells during the early stage of disease and increased the infiltration of T cells, TGF-β-producing monocytes/macrophages, and Th2 cells into the skin in the later stage of Scl-cGVHD. IL-10-producing regulatory B cells (B10 cells) were not reconstituted by CD19(-/-) donor cells, and early adoptive transfer of B10 cells attenuated the augmented manifestations of CD19(-/-) donor-induced Scl-cGVHD. Therefore, donor-derived B10 cells have a suppressive role in Scl-cGVHD development, warranting future investigation of regulatory B-cell-based therapy for treatment of Scl-cGVHD and SSc.
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Yilmaz M, Ozdemir F, Akbulut S, Ersan V, Koc C, Koc S, Yilmaz S. Chronic graft-versus-host disease after liver transplantation: a case report. Transplant Proc 2012; 44:1751-3. [PMID: 22841262 DOI: 10.1016/j.transproceed.2012.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Graft-versus-host disease (GVHD) after orthotopic liver transplantation (OLT) is a rare but significant complication, occurring in 1%-2% of cases with a mortality rate of 85%- 90%. It occurs when donor passenger lymphocytes mount an alloreactive response against the host's histocompatibility antigens. It presents as fever, rash, and diarrhea with or without pancytopenia. Between March 2002 and September 2011, among 656 OLT patients 1 (0.15%) had acute GVHD. A biopsy at the 7th posttransplantation month revealed chronic GVHD. Consequently, in the cases that had fever, rash, and/or desquamation of the any part of body after liver transplantation, GVHD must be considered and skin biopsies must be planned for the diagnosis.
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Affiliation(s)
- M Yilmaz
- Department of Surgery, Division of Liver Traansplantation, Inonu University Faculty of Medicine, Malatya, Turkey.
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37
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Hymes SR, Alousi AM, Cowen EW. Graft-versus-host disease: part I. Pathogenesis and clinical manifestations of graft-versus-host disease. J Am Acad Dermatol 2012; 66:515.e1-18; quiz 533-4. [PMID: 22421123 DOI: 10.1016/j.jaad.2011.11.960] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/09/2011] [Accepted: 11/12/2011] [Indexed: 01/04/2023]
Abstract
Approximately 25,000 allogeneic hematopoietic cell transplants are performed worldwide each year for a variety of malignant and non-malignant conditions. Graft-versus-host disease represents one of the most frequent complications and is a major source of long-term morbidity and mortality. Whereas acute graft-versus-host disease is induced by recognition of host tissues as foreign by immunocompetent donor cells, the pathogenesis of chronic graft-versus-host disease is not as well understood, and continues to be a major treatment challenge. Part I of this two-part series reviews the epidemiologic factors, classification, pathogenesis, and clinical manifestations of acute and chronic graft-versus-host disease. Part II discusses the topical, physical, and systemic treatment options available to patients with graft-versus-host disease.
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Affiliation(s)
- Sharon R Hymes
- Department of Dermatology, University of Texas MD Anderson Cancer Center, Houston, Texas 77030-4009, USA.
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Ortín M, Sierra J. Use of mesenchymal stem cells as treatment for graft-versus-host disease: current knowledge and controversies. Immunotherapy 2012; 3:701-4. [PMID: 21668303 DOI: 10.2217/imt.11.65] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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Mo XD, Xu LP, Liu DH, Chen YH, Han W, Zhang XH, Chen H, Wang Y, Wang JZ, Liu KY, Huang XJ. Patients receiving HLA-haploidentical/partially matched related allo-HSCT can achieve desirable health-related QoL that is comparable to that of patients receiving HLA-identical sibling allo-HSCT. Bone Marrow Transplant 2012; 47:1201-5. [PMID: 22231459 DOI: 10.1038/bmt.2011.250] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To investigate the health-related quality of life (HRQoL) of patients receiving allogeneic hematopoietic SCT (allo-HSCT) from HLA-haploidentical/partially matched related donors (HID/PMRD) and to compare this value with that of patients receiving allo-HSCT from HLA-identical sibling donor (ISD), a total of 350 patients receiving allo-HSCT were enrolled in a study (ISD: 173; HID/PMRD: 177). HRQoL post transplantation was evaluated by an SF-36 questionnaire. The effect of various factors on the HRQoL was analyzed through COX regression. Compared with the ISD group, patients in the HID/PMRD group had higher scores in physical functioning, general health, bodily pain, vitality and emotional role functioning, and these patients functioned significantly better on the physical and mental component summaries. Also, long-term survivors exhibit better HRQoL. Measured by multivariate analysis, extensive chronic GVHD was observed to have a strongly negative impact on patients' HRQoL, while male gender status, lower age when receiving allo-HSCT and returning to work or school were associated with positive impacts on at least one subscale. These results showed that the HRQoL of patients receiving HID/PMRD hematopoietic SCT (HSCT) is comparable to that of patients receiving ISD HSCT, and HLA disparity is not the factor affecting the HRQoL.
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Affiliation(s)
- X-D Mo
- Peking University People's Hospital, Institute of Hematology, Beijing, PR China
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Significantly worse survival of patients with NIH-defined chronic graft-versus-host disease and thrombocytopenia or progressive onset type: results of a prospective study. Leukemia 2011; 26:746-56. [PMID: 21926960 DOI: 10.1038/leu.2011.257] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Chronic graft-versus-host disease (GVHD) remains a serious complication after allogeneic hematopoietic stem cell transplantation (HCT). In 2005 the National Institutes of Health (NIH) established new criteria for chronic GVHD based on retrospective data and expert recommendations. We prospectively evaluated the incidence of NIH-defined chronic GVHD and its prognostic impact in 178 consecutive patients. The cumulative incidence of chronic GVHD at 3 years was 64, 48 and 16% for chronic classic GVHD and overlap syndrome. Prior acute GVHD and myeloablative conditioning were significantly associated with increased risk of chronic GVHD. Three-year survival (overall survival (OS)) for late-acute GVHD, chronic classic and overlap chronic GVHD when assigned on day 100 were 69, 83 and 73%. OS was significantly worse for patients with platelet counts below 100 g/l at onset of chronic GVHD (35% versus 86%, P<0.0001) and progressive as compared with de novo and quiescent onset of chronic GVHD (54.5% versus 89.5% versus 84%, P = 0.022 and 0.001). Peak severity of chronic GVHD had no impact on non-relapse mortality (NRM) and OS. Recurrent acute GVHD, platelet counts below 100 g/l at diagnosis of chronic GVHD, progressive onset of chronic GVHD and advanced disease stage prior to HCT were significantly associated with increased NRM. This prospective analysis provides for the first-time data on the incidence rates of NIH-defined chronic GVHD categories and identified risk factors for the occurrence of chronic GVHD. A prognostic value of thrombocytopenia and progressive onset type of chronic GVHD for survival after HCT was observed in NIH-defined chronic GVHD.
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41
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HU STEPHANIEW, COTLIAR JONATHAN. Acute graft-versus-host disease following hematopoietic stem-cell transplantation. Dermatol Ther 2011; 24:411-23. [DOI: 10.1111/j.1529-8019.2011.01436.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Mii A, Shimizu A, Kaneko T, Fujita E, Fukui M, Fujino T, Utsumi K, Yamaguchi H, Tajika K, Tsuchiya SI, Iino Y, Katayama Y, Fukuda Y. Renal thrombotic microangiopathy associated with chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Pathol Int 2011; 61:518-27. [PMID: 21884301 DOI: 10.1111/j.1440-1827.2011.02704.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Thrombotic microangiopathy (TMA) is a major complication after hematopoietic stem cell transplantation (HSCT). In this study, we examined the clinical and pathologic features of 2 patients and 5 autopsy cases with HSCT-associated renal TMA to clarify the association between graft-versus-host disease (GVHD) and renal TMA. The median interval between HSCT and renal biopsy or autopsy was 7 months (range 3-42 months). Clinically, acute and chronic GVHD occurred in 7 and 4 patients, respectively. Clinical evidence for TMA was detected in 2 patients, while chronic kidney disease developed in all patients. The main histopathological findings were diffuse endothelial injury in glomeruli, peritubular capillaries (PTCs), and small arteries. In addition, all cases showed glomerulitis, renal tubulitis, and peritubular capillaritis with infiltration of CD3+ T cells and TIA-1+ cytotoxic cells, suggesting that GVHD occurred during the development of TMA. Diffuse and patchy C4d deposition was noted in glomerular capillaries and PTCs, respectively, in 2 biopsy and 2 autopsy cases, suggesting the involvement of antibody-mediated renal endothelial injury in more than 50% of renal TMA cases. In conclusion, the kidney is a potential target of chronic GVHD that may induce the development of HSCT-associated TMA. Importantly, some cases are associated with chronic humoral GVHD.
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Affiliation(s)
- Akiko Mii
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
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Kolins JA, Zbylut C, McCollom S, Aquino VM. Hematopoietic Stem Cell Transplantation in Children. Crit Care Nurs Clin North Am 2011; 23:349-76. [DOI: 10.1016/j.ccell.2011.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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45
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Edelmann SL, Marconi P, Brocker T. Peripheral T cells re-enter the thymus and interfere with central tolerance induction. THE JOURNAL OF IMMUNOLOGY 2011; 186:5612-9. [PMID: 21471449 DOI: 10.4049/jimmunol.1004010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The thymus mainly contains developing thymocytes that undergo thymic selection. In addition, some mature activated peripheral T cells can re-enter the thymus. We demonstrated in this study that adoptively transferred syngeneic Ag-specific T cells can enter the thymus of lymphopenic mice, where they delete thymic dendritic cells and medullary thymic epithelial cells in an Ag-specific fashion, without altering general thymic functions. This induced sustained thymic release of autoreactive self-Ag-specific T cells suggested that adoptively transferred activated T cells can specifically alter the endogenous T cell repertoire by erasing negative selection of their own specificities. Especially in clinical settings in which adoptively transferred T cells cause graft-versus-host disease or graft-versus-leukemia, as well as in adoptive tumor therapies, these findings might be of importance, because the endogenous T cell repertoire might be skewed to contribute to both manifestations.
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Affiliation(s)
- Stephanie L Edelmann
- Institute for Immunology, Ludwig-Maximilians-University, D-80336 Munich, Germany
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Sato T, Ichinohe T, Kanda J, Yamashita K, Kondo T, Ishikawa T, Uchiyama T, Takaori-Kondo A. Clinical significance of subcategory and severity of chronic graft-versus-host disease evaluated by National Institutes of Health consensus criteria. Int J Hematol 2011; 93:532-541. [DOI: 10.1007/s12185-011-0820-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 02/21/2011] [Accepted: 03/16/2011] [Indexed: 10/18/2022]
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47
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Araújo F, Kelmann R, Araújo B, Finatto R, Teixeira H, Koester L. Development and characterization of parenteral nanoemulsions containing thalidomide. Eur J Pharm Sci 2011; 42:238-45. [DOI: 10.1016/j.ejps.2010.11.014] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 11/09/2010] [Accepted: 11/25/2010] [Indexed: 11/25/2022]
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48
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Vigorito AC, Bouzas LFDS, Moreira MCR, Funke VAM, Colturato VAR, Pedro A, Souza CVD, Nunes EC, Miranda ECM, Camacho K, Mauad MA, Correa MEP, Silva MDM, Sousa MPD, Tavares RDCBDS, Lee SJ, Flowers MED. A multicenter feasibility study of chronic graft-versus-host disease according to the National Institute of Health criteria: efforts to establish a Brazil-Seattle consortium as a platform for future collaboration in clinical trials. Rev Bras Hematol Hemoter 2011; 33:283-289. [PMID: 22328863 PMCID: PMC3276599 DOI: 10.5581/1516-8484.20110078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND: New criteria for the diagnosis and classification of chronic graft-versus-host disease were developed in 2005 for the purpose of clinical trials with a consensus sponsored by the National Institute of Health. OBJECTIVES: The aim of this study is to present the results of a multicenter pilot study performed by the Brazil-Seattle chronic graft-versus-host disease consortium to determine the feasibility of using these criteria in five Brazilian centers. METHODS: The study was performed after translation of the consensus criteria into Portuguese and training. A total of 34 patients with National Institute of Health chronic graft-versus-host disease were enrolled in the pilot study between June 2006 and May 2009. RESULTS: Of the 34 patients, 26 (76%) met the criteria of overlap syndrome and eight (24%) the classic subcategory. The overall severity of disease was moderate in 21 (62%) and severe in 13 (38%) patients. The median time from transplant to onset of chronic graft-versus-host disease was 5.9 months (Range: 3 - 16 months); the median time for the overlap syndrome subcategory was 5.9 months (Range: 3 - 10 months) and for the classic subcategory, it was 7.3 months (Range: 3 - 16 months). At a median follow up of 16.5 months (Range: 4 - 39 months), overall survival was 75%. CONCLUSIONS: It was feasible to use the National Institute of Health consensus criteria for the diagnosis and scoring of chronic graft-versus-host disease in a Brazilian prospective multicenter study. More importantly, a collaborative hematopoietic cell transplantation network was established in Brazil offering new opportunities for future clinical trials in chronic graft-versus-host disease and in other areas of research involving hematopoietic stem cell transplantation.
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49
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Kim SJ, Choi JM, Kim JE, Cho BK, Kim DW, Park HJ. Clinicopathologic characteristics of cutaneous chronic graft-versus-host diseases: a retrospective study in Korean patients. Int J Dermatol 2010; 49:1386-92. [DOI: 10.1111/j.1365-4632.2010.04552.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Significant differences in B-cell subpopulations characterize patients with chronic graft-versus-host disease-associated dysgammaglobulinemia. Blood 2010; 117:2265-74. [PMID: 21063025 DOI: 10.1182/blood-2010-07-295766] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Manifestations of chronic graft-versus-host disease (cGVHD) can resemble those seen in immunodeficiency states and autoimmune disorders. Reports by us and others suggest an involvement of B cells in the pathogenesis of cGVHD. We investigated B-lymphocyte subpopulations in cGVHD cohorts defined by serum immunoglobulin G (IgG) levels to characterize novel biomarkers for impairment of humoral immunity after allogeneic hematopoietic stem cell transplantation. Seventy-six patients were enrolled a median of 46 months after hematopoietic stem cell transplantation. The hypogammaglobulinemia group had significantly diminished CD19(+) B cells (165 vs 454 vs 417 × 10⁶L) with elevated CD19(+)CD21(low) immature (16.5%, 7.7%, and 9.1%) and CD19(+)CD21(int-high)CD38(high)IgM(high) transitional (10.5% vs 4.2% vs 6.3%) B-cell proportions compared with the normogammaglobulinemia and hypergammaglobulinemia groups. CD19(+)CD10(-)CD27(-)CD21(high) naive B cells were highly elevated in all patients with cGVHD. CD19(+)CD27(+)IgD(+) non-class-switched (4 vs 12 vs 11 × 10⁶/L) and class-switched (7 vs 35 vs 42 × 10⁶/L) memory B cells were significantly lower in the hypogammaglobulinemia group compared with the others. Besides significantly higher B-cell activation factor/B-cell ratios, significantly more cGVHD patients with hypergammaglobulinemia had autoantibodies compared with the hypogammaglobulinemia subgroup (68% vs 24%, P = .024). In conclusion, B-cell subpopulations can serve as novel cellular biomarkers for immunodeficiency and autoimmunity indicating different pathogenetic mechanisms of cGVHD and encouraging future prospective longitudinal studies.
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