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Zhang X, Zhao X, Chen S, Hao M, Zhang L, Gong M, Shi Y, Wei J, Zhang P, Feng S, He Y, Jiang E, Han M. Addition of ruxolitinib to standard graft-versus-host disease prophylaxis for allogeneic stem cell transplantation in aplastic anemia patients. Bone Marrow Transplant 2024; 59:997-1005. [PMID: 38580777 PMCID: PMC11226399 DOI: 10.1038/s41409-024-02266-7] [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: 11/06/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 04/07/2024]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) offers rapid hematopoietic and immune reconstitution for aplastic anemia (AA). As a non-malignant disorder, attenuation of GVHD remains a clinical priority in AA patients. Our study sought to investigate the safety and efficacy of the prophylactic use of ruxolitinib in allogeneic HSCT. A total of 35 AA patients were retrospectively consecutively treated with allo-HSCT whereby ruxolitinib was added to the standard GVHD prophylaxis regimen (rux group). The addition of peri-transplant ruxolitinib did not impact the engraftment and graft function, while better recovery of CD4+ Tregs in the rux group was observed. Interestingly, the rux group demonstrated significantly lower incidence of bacterial/fungal infections (17.14% vs 45.71%). Compared to the control group, the rux group exhibited significantly lower incidence of moderate to severe aGVHD (17.1% vs 48.6%) with a trend toward lower severe aGVHD (8.6% vs 20%) and cGVHD (26.2 vs 38.3). The rux group also demonstrated a trend toward higher GVHD and failure-free survival (GFFS: 85.7% vs 68.6%) and lower TRM (2.9% vs 14.3%). Addition of ruxolitinib to standard GVHD prophylaxis regimen, thus, represents a safe and highly efficient method for the attenuation of GVHD with better outcome of allo-HSCT.
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Affiliation(s)
- Xiaoyu Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Xiaoli Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Shulian Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Mengze Hao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Lining Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ming Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yuanyuan Shi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Ping Zhang
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, 98109, USA
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
| | - Yi He
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China.
- Tianjin Institutes of Health Science, Tianjin, 301600, China.
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China.
- Tianjin Institutes of Health Science, Tianjin, 301600, China.
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300060, China
- Tianjin Institutes of Health Science, Tianjin, 301600, China
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Chopra Y, Acevedo K, Muise A, Frost K, Schechter T, Krueger J, Ali M, Chiang KY, Kim VHD, Grunebaum E, Wall D. Gut Immunomodulation with Vedolizumab prior to Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Patients with Inflammatory Bowel Disease. Transplant Cell Ther 2024; 30:546.e1-546.e7. [PMID: 38458476 DOI: 10.1016/j.jtct.2024.03.006] [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: 11/20/2023] [Revised: 03/03/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
Inborn errors of immunity (IEI) are often associated with inflammatory bowel disease (IBD). IEI can be corrected by allogeneic hematopoietic stem cell transplantation (HSCT); however, peritransplantation intestinal inflammation may increase the risk of gut graft-versus-host disease (GVHD). Vedolizumab inhibits the homing of lymphocytes to the intestine and may attenuate gut GVHD, yet its role in preventing GVHD in pediatric patients with IEI-associated IBD has not been studied. Here we describe a cohort of pediatric patients with IEI-associated IBD treated with vedolizumab before and during allogeneic HSCT. The study involved a retrospective chart review of pediatric patients with IEI-associated IBD treated with vedolizumab at 6 weeks, 4 weeks, and 1 week before undergoing HSCT. The conditioning regimen consisted of treosulfan, fludarabine, and cyclophosphamide with rabbit antithymocyte globulin, and GVHD prophylaxis included tacrolimus and steroids. Eleven patients (6 females) with a median age of 5 years (range, 0.4 to 14 years) with diverse IEI were included. IBD symptoms were characterized by abdominal pain, loose stools, and blood in stools. Four patients had developed a perianal fistula, and 1 patient had a rectal prolapse. One patient had both a gastrostomy tube and a jejunal tube in situ. Treatment of IBD before HSCT included steroids in 11 patients, anakinra in 2, infliximab in 4, sulfasalazine in 2, mesalazine in 2, and vedolizumab. IBD symptoms were considered controlled in the absence of abdominal pain, loose stools, or blood in stools. Graft sources for HSCT were unrelated donor cord in 5 patients (2 with a 5/8 HLA match, 2 with a 7/8 match, and 1 with a 6/8 match), peripheral blood stem cells in 5 patients (2 haploidentical, 1 with a 9/10 HLA match, and 2 with a 10/10 match), and bone marrow in 1 patient (10/10 matched sibling donor). The median number of vedolizumab infusions was 4 (range, 3 to 12) before HSCT and 1 (range, 1 to 3) after HSCT, and all were reported to be uneventful. All patients had engrafted. Acute GVHD occurred in 4 patients and was limited to grade I skin GVHD only. Chronic GVHD occurred in 1 patient and again was limited to the skin. There was no gut GVHD. Three patients experienced cytomegalovirus viremia, and 2 patients had Epstein-Barr virus viremia. At the time of this report, all patients were alive with no evidence of IBD at a median follow-up of 15 months (range, 3 to 39 months). Administration of vedolizumab pre- and post-HSCT in pediatric patients with IEI-associated IBD is well tolerated and associated with a low rate of gut GVHD. These findings provide a platform for the prospective study and use of vedolizumab for GVHD prophylaxis in pediatric patients with known intestinal inflammation as a pre-HSCT comorbidity.
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Affiliation(s)
- Yogi Chopra
- Division of Hematology/Oncology, Blood and Marrow Transplant/Cellular Therapy, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Karol Acevedo
- Division of Hematology/Oncology, Blood and Marrow Transplant/Cellular Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aleixo Muise
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karen Frost
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tal Schechter
- Division of Hematology/Oncology, Blood and Marrow Transplant/Cellular Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joerg Krueger
- Division of Hematology/Oncology, Blood and Marrow Transplant/Cellular Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Muhammad Ali
- Division of Hematology/Oncology, Blood and Marrow Transplant/Cellular Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kuang-Yueh Chiang
- Division of Hematology/Oncology, Blood and Marrow Transplant/Cellular Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vy Hong-Diep Kim
- Division of Immunology and Allergy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eyal Grunebaum
- Division of Immunology and Allergy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Donna Wall
- Division of Hematology/Oncology, Blood and Marrow Transplant/Cellular Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
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Baert L, Mahmudul HM, Stegall M, Joo H, Oh S. B Cell-mediated Immune Regulation and the Quest for Transplantation Tolerance. Transplantation 2024:00007890-990000000-00669. [PMID: 38389135 DOI: 10.1097/tp.0000000000004948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Pathophysiologic function of B cells in graft rejection has been well recognized in transplantation. B cells promote alloantigen-specific T-cell response and secrete antibodies that can cause antibody-mediated graft failures and rejections. Therefore, strategies targeting B cells, for example, B-cell depletion, have been used for the prevention of both acute and chronic rejections. Interestingly, however, recent mounting evidence indicates that subsets of B cells yet to be further identified can display potent immune regulatory functions, and they contribute to transplantation tolerance and operational tolerance in both experimental and clinical settings, respectively. In this review, we integrate currently available information on B-cell subsets, including T-cell Ig domain and mucin domain 1-positive transitional and T-cell immunoreceptor with Ig and immunoreceptor tyrosine-based inhibitory motif domain-positive memory B cells, displaying immune regulatory functions, with a focus on transplantation tolerance, by analyzing their mechanisms of action. In addition, we will discuss potential T-cell Ig domain and mucin domain 1-positive and T-cell immunoreceptor with Ig and immunoreceptor tyrosine-based inhibitory motif domain-positive B cell-based strategies for the enhancement of operational tolerance in transplantation patients.
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Affiliation(s)
- Laurie Baert
- Department of Immunology, Mayo Clinic, Scottsdale, AZ
| | | | - Mark Stegall
- Department of Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - HyeMee Joo
- Department of Immunology, Mayo Clinic, Scottsdale, AZ
| | - SangKon Oh
- Department of Immunology, Mayo Clinic, Scottsdale, AZ
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4
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De Togni E, Cole O, Abboud R. Janus kinase inhibition in the treatment and prevention of graft-versus-host disease. Front Immunol 2024; 15:1304065. [PMID: 38380328 PMCID: PMC10877010 DOI: 10.3389/fimmu.2024.1304065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
Graft-versus-host disease (GVHD) is a significant cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). For many years, corticosteroids have been the mainstay treatment for GVHD, but cases of steroid-refractory GVHD and the severe adverse effects of high-dose corticosteroids have increased the need for preventative and therapeutic strategies for GVHD. Due to the nature of alloreactive T cells, GVHD is inherently linked to the graft-versus-leukemia (GVL) effect, the therapeutic driving force behind stem cell transplantation. A considerable clinical challenge is to preserve GVL while suppressing GVHD. The field of GVHD research has greatly expanded over the past decades, including advancements in T cell modulation and depletion, antibody therapies, chemotherapeutics, cellular therapies, and Janus kinase inhibition. In this review, we discuss current approaches and advances in the prophylaxis and treatment of GVHD with a focus on new emerging advancements in Janus kinase inhibitor therapy.
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Affiliation(s)
- Elisa De Togni
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Oladipo Cole
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Ramzi Abboud
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, United States
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5
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Quann K, Sacirbegovic F, Shlomchik WD. Natalizumab for GVHD: too little or too late? Blood Adv 2023; 7:5187-5188. [PMID: 37698891 PMCID: PMC10505719 DOI: 10.1182/bloodadvances.2023010486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Affiliation(s)
- Kevin Quann
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Faruk Sacirbegovic
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Warren D Shlomchik
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Starzl Transplantation Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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6
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Al Malki MM, London K, Baez J, Akahoshi Y, Hogan WJ, Etra A, Choe H, Hexner E, Langston A, Abhyankar S, Ponce DM, DeFilipp Z, Kitko CL, Adekola K, Reshef R, Ayuk F, Capellini A, Chanswangphuwana C, Eder M, Eng G, Gandhi I, Grupp S, Gleich S, Holler E, Javorniczky NR, Kasikis S, Kowalyk S, Morales G, Özbek U, Rösler W, Spyrou N, Yanik G, Young R, Chen YB, Nakamura R, Ferrara JLM, Levine JE. Phase 2 study of natalizumab plus standard corticosteroid treatment for high-risk acute graft-versus-host disease. Blood Adv 2023; 7:5189-5198. [PMID: 37235690 PMCID: PMC10505783 DOI: 10.1182/bloodadvances.2023009853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023] Open
Abstract
Graft-versus-host disease (GVHD) of the gastrointestinal (GI) tract is the main cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation. Ann Arbor (AA) scores derived from serum biomarkers at onset of GVHD quantify GI crypt damage; AA2/3 scores correlate with resistance to treatment and higher NRM. We conducted a multicenter, phase 2 study using natalizumab, a humanized monoclonal antibody that blocks T-cell trafficking to the GI tract through the α4 subunit of α4β7 integrin, combined with corticosteroids as primary treatment for patients with new onset AA2/3 GVHD. Seventy-five patients who were evaluable were enrolled and treated; 81% received natalizumab within 2 days of starting corticosteroids. Therapy was well tolerated with no treatment emergent adverse events in >10% of patients. Outcomes for patients treated with natalizumab plus corticosteroids were compared with 150 well-matched controls from the MAGIC database whose primary treatment was corticosteroids alone. There were no significant differences in overall or complete response between patients treated with natalizumab plus corticosteroids and those treated with corticosteroids alone (60% vs 58%; P = .67% and 48% vs 48%; P = 1.0, respectively) including relevant subgroups. There were also no significant differences in NRM or overall survival at 12 months in patients treated with natalizumab plus corticosteroids compared with controls treated with corticosteroids alone (38% vs 39%; P = .80% and 46% vs 54%; P = .48, respectively). In this multicenter biomarker-based phase 2 study, natalizumab combined with corticosteroids failed to improve outcome of patients with newly diagnosed high-risk GVHD. This trial was registered at www.clinicaltrials.gov as # NCT02133924.
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Affiliation(s)
- Monzr M. Al Malki
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Kaitlyn London
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Janna Baez
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yu Akahoshi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Aaron Etra
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hannah Choe
- Division of Hematology, James Cancer Center, The Ohio State University, Columbus, OH
| | - Elizabeth Hexner
- Blood and Marrow Transplantation Program, Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Sunil Abhyankar
- Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS
| | - Doris M. Ponce
- Division of Hematology/Oncology, Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering, New York, NY
| | - Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Carrie L. Kitko
- Pediatric Stem Cell Transplant Program, Vanderbilt University Medical Center, Nashville, TN
| | - Kehinde Adekola
- Division of Hematology/Oncology, Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ran Reshef
- Blood and Marrow Transplantation, Columbia University Medical Center, New York, NY
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Capellini
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Chantiya Chanswangphuwana
- Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Gilbert Eng
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Isha Gandhi
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan Grupp
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nora Rebeka Javorniczky
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, Albert Ludwigs University, Freiburg, Germany
| | - Stelios Kasikis
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Umut Özbek
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wolf Rösler
- Department of Internal Medicine 5, University Hospital Erlangen, Erlangen, Germany
| | - Nikolaos Spyrou
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gregory Yanik
- Blood and Marrow Transplant Program, Michigan Medicine, Ann Arbor, MI
| | - Rachel Young
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ryotaro Nakamura
- Hematology/Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - James L. M. Ferrara
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John E. Levine
- The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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[Vedolizumab for treatment of steroid-refractory intestinal acute graft-versus-host disease: two cases report and literature review]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:1046-1049. [PMID: 36709113 PMCID: PMC9939336 DOI: 10.3760/cma.j.issn.0253-2727.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Kurya AU, Aliyu U, Tudu AI, Usman A, Yusuf M, Gupta S, Ali A, Gulfishan M, Singh SK, Hussain I, Abubakar MG. Graft-versus-host disease: Therapeutic prospects of improving the long-term post-transplant outcomes. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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9
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Li ACW, Dong C, Tay ST, Ananthakrishnan A, Ma KSK. Vedolizumab for acute gastrointestinal graft-versus-host disease: A systematic review and meta-analysis. Front Immunol 2022; 13:1025350. [PMID: 36439135 PMCID: PMC9692080 DOI: 10.3389/fimmu.2022.1025350] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/26/2022] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE To determine the safety and efficacy of vedolizumab for the prophylaxis and treatment of gastrointestinal involvement of acute graft-versus-host disease (GVHD) (GI-aGVHD). METHODS Literature search within PubMed, EMBASE, Web of Science, and Cochrane Library for observational studies and clinical trials that evaluated the effect of vedolizumab on GI-aGVHD was done through 17 May 2022. A bivariate and random-effect meta-analysis derived the pooled observational percentages and pooled risk ratios (RRs) from baseline of primary endpoints including overall response, complete response, mortality, and adverse events. RESULTS There was a total of 122 participants in eight eligible studies, including one study on the prophylactic use of vedolizumab and seven studies on vedolizumab for the treatment of GI-aGVHD. Of seven studies that reported details on baseline grades of GI-aGVHD, a total of 47 patients (47.95%) were of stage 4, 31 patients (31.63%) were of stage 3, 10 patients (10.2%) were of stage 2, and 10 patients (10.2%) were of stage 1. The use of vedolizumab for the treatment of GI-aGVHD yielded a significantly improved objective response rate (ORR) at 14 days (pooled ORR = 60.53%, pooled RR = 14.14, 95% CI: 2.95-67.71), 28 days (pooled ORR = 50%, RR = 7.36, 95% CI = 2.14-25.37), and 12 months (pooled ORR = 76.92%, RR = 13.66, 95% CI = 3.5-53.35) from baseline. Likewise, the use of vedolizumab was followed by a significantly improved complete response (CR) at 12 months (pooled CR = 27.27%, RR = 5.50, 95% CI = 1.01-29.95), yet the CR at 14 days and 28 days did not reach statistical significance. Fifty-seven out of 87 (pooled overall survival, OS = 34.5%) and 46 out of 65 (pooled OS = 29.2%) patients expired at 6 and 12 months after the use of vedolizumab, respectively. Prophylactic use of vedolizumab was not associated with any specific type of reported adverse events, while patients with GI-aGVHD on vedolizumab presented with significantly increased risks of adverse events including infections (RR = 7.55) and impaired metabolism or nutritional complications (RR = 9.00). All analyses were of a low heterogeneity (all I-squares = 0%). CONCLUSION Vedolizumab was safe and effective for the prophylaxis and management of early grade GI-aGVHD. More clinical evidence is warranted to validate these findings. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=345584, identifier CRD42022345584.
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Affiliation(s)
- Allen Cheng-Wei Li
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Medical Education, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chen Dong
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Soon-Tzeh Tay
- Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ashwin Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Kevin Sheng-Kai Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Department of Dermatology, Massachusetts General Hospital, Boston, MA, United States
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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10
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Hippen KL, Hefazi M, Larson JH, Blazar BR. Emerging translational strategies and challenges for enhancing regulatory T cell therapy for graft-versus-host disease. Front Immunol 2022; 13:926550. [PMID: 35967386 PMCID: PMC9366169 DOI: 10.3389/fimmu.2022.926550] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/27/2022] [Indexed: 02/03/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative therapy for many types of cancer. Genetic disparities between donor and host can result in immune-mediated attack of host tissues, known as graft versus host disease (GVHD), a major cause of morbidity and mortality following HSCT. Regulatory CD4+ T cells (Tregs) are a rare cell type crucial for immune system homeostasis, limiting the activation and differentiation of effector T cells (Teff) that are self-reactive or stimulated by foreign antigen exposure. Adoptive cell therapy (ACT) with Treg has demonstrated, first in murine models and now in patients, that prophylactic Treg infusion can also suppress GVHD. While clinical trials have demonstrated Treg reduce severe GVHD occurrence, several impediments remain, including Treg variability and practical need for individualized Treg production for each patient. Additionally, there are challenges in the use of in vitro expansion techniques and in achieving in vivo Treg persistence in context of both immune suppressive drugs and in lymphoreplete patients being treated for GVHD. This review will focus on 3 main translational approaches taken to improve the efficacy of tTreg ACT in GVHD prophylaxis and development of treatment options, following HSCT: genetic modification, manipulating TCR and cytokine signaling, and Treg production protocols. In vitro expansion for Treg ACT presents a multitude of approaches for gene modification to improve efficacy, including: antigen specificity, tissue targeting, deletion of negative regulators/exhaustion markers, resistance to immunosuppressive drugs common in GVHD treatment. Such expansion is particularly important in patients without significant lymphopenia that can drive Treg expansion, enabling a favorable Treg:Teff ratio in vivo. Several potential therapeutics have also been identified that enhance tTreg stability or persistence/expansion following ACT that target specific pathways, including: DNA/histone methylation status, TCR/co-stimulation signaling, and IL-2/STAT5 signaling. Finally, this review will discuss improvements in Treg production related to tissue source, Treg subsets, therapeutic approaches to increase Treg suppression and stability during tTreg expansion, and potential for storing large numbers of Treg from a single production run to be used as an off-the-shelf infusion product capable of treating multiple recipients.
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Affiliation(s)
- Keli L. Hippen
- University of Minnesota Cancer Center and the Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, Minneapolis, MN, United States
| | - Mehrdad Hefazi
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Jemma H. Larson
- University of Minnesota Cancer Center and the Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, Minneapolis, MN, United States
| | - Bruce R. Blazar
- University of Minnesota Cancer Center and the Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, Minneapolis, MN, United States
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11
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DeFilipp Z, Hefazi M, Chen YB, Blazar BR. Emerging approaches to improve allogeneic hematopoietic cell transplantation outcomes for nonmalignant diseases. Blood 2022; 139:3583-3593. [PMID: 34614174 PMCID: PMC9728560 DOI: 10.1182/blood.2020009014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/04/2021] [Indexed: 12/14/2022] Open
Abstract
Many congenital or acquired nonmalignant diseases (NMDs) of the hematopoietic system can be potentially cured by allogeneic hematopoietic cell transplantation (HCT) with varying types of donor grafts, degrees of HLA matching, and intensity of conditioning regimens. Unique features that distinguish the use of allogeneic HCT in this population include higher rates of graft failure, immune-mediated cytopenias, and the potential to achieve long-term disease-free survival in a mixed chimerism state. Additionally, in contrast to patients with hematologic malignancies, a priority is to completely avoid graft-versus-host disease in patients with NMD because there is no theoretical beneficial graft-versus-leukemia effect that can accompany graft-versus-host responses. In this review, we discuss the current approach to each of these clinical issues and how emerging novel therapeutics hold promise to advance transplant care for patients with NMDs.
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Affiliation(s)
- Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | | | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Bruce R. Blazar
- Department of Pediatrics, Division of Blood & Marrow Transplant & Cellular Therapy, University of Minnesota, Minneapolis, MN
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12
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Griffin JM, Healy FM, Dahal LN, Floisand Y, Woolley JF. Worked to the bone: antibody-based conditioning as the future of transplant biology. J Hematol Oncol 2022; 15:65. [PMID: 35590415 PMCID: PMC9118867 DOI: 10.1186/s13045-022-01284-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/06/2022] [Indexed: 11/29/2022] Open
Abstract
Conditioning of the bone marrow prior to haematopoietic stem cell transplant is essential in eradicating the primary cause of disease, facilitating donor cell engraftment and avoiding transplant rejection via immunosuppression. Standard conditioning regimens, typically comprising chemotherapy and/or radiotherapy, have proven successful in bone marrow clearance but are also associated with severe toxicities and high incidence of treatment-related mortality. Antibody-based conditioning is a developing field which, thus far, has largely shown an improved toxicity profile in experimental models and improved transplant outcomes, compared to traditional conditioning. Most antibody-based conditioning therapies involve monoclonal/naked antibodies, such as alemtuzumab for graft-versus-host disease prophylaxis and rituximab for Epstein–Barr virus prophylaxis, which are both in Phase II trials for inclusion in conditioning regimens. Nevertheless, alternative immune-based therapies, including antibody–drug conjugates, radio-labelled antibodies and CAR-T cells, are showing promise in a conditioning setting. Here, we analyse the current status of antibody-based drugs in pre-transplant conditioning regimens and assess their potential in the future of transplant biology.
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Affiliation(s)
- James M Griffin
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Fiona M Healy
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Lekh N Dahal
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | - Yngvar Floisand
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK.,The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - John F Woolley
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK.
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13
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Challenges and opportunities targeting mechanisms of epithelial injury and recovery in acute intestinal graft-versus-host disease. Mucosal Immunol 2022; 15:605-619. [PMID: 35654837 PMCID: PMC9259481 DOI: 10.1038/s41385-022-00527-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/21/2022] [Accepted: 05/16/2022] [Indexed: 02/04/2023]
Abstract
Despite advances in immunosuppressive prophylaxis and overall supportive care, gastrointestinal (GI) graft-versus-host disease (GVHD) remains a major, lethal side effect after allogeneic hematopoietic stem cell transplantation (allo-HSCT). It has become increasingly clear that the intestinal epithelium, in addition to being a target of transplant-related toxicity and GVHD, plays an important role in the onset of GVHD. Over the last two decades, increased understanding of the epithelial constituents and their microenvironment has led to the development of novel prophylactic and therapeutic interventions, with the potential to protect the intestinal epithelium from GVHD-associated damage and promote its recovery following insult. In this review, we will discuss intestinal epithelial injury and the role of the intestinal epithelium in GVHD pathogenesis. In addition, we will highlight possible approaches to protect the GI tract from damage posttransplant and to stimulate epithelial regeneration, in order to promote intestinal recovery. Combined treatment modalities integrating immunomodulation, epithelial protection, and induction of regeneration may hold the key to unlocking mucosal recovery and optimizing therapy for acute intestinal GVHD.
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14
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Teshima T, Hill GR. The Pathophysiology and Treatment of Graft- Versus-Host Disease: Lessons Learnt From Animal Models. Front Immunol 2021; 12:715424. [PMID: 34489966 PMCID: PMC8417310 DOI: 10.3389/fimmu.2021.715424] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/26/2021] [Indexed: 12/11/2022] Open
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is a curative treatment for hematologic malignancies, bone marrow failure syndromes, and inherited immunodeficiencies and metabolic diseases. Graft-versus-host disease (GVHD) is the major life-threatening complication after allogeneic HCT. New insights into the pathophysiology of GVHD garnered from our understanding of the immunological pathways within animal models have been pivotal in driving new therapeutic paradigms in the clinic. Successful clinical translations include histocompatibility matching, GVHD prophylaxis using cyclosporine and methotrexate, posttransplant cyclophosphamide, and the use of broad kinase inhibitors that inhibit cytokine signaling (e.g. ruxolitinib). New approaches focus on naïve T cell depletion, targeted cytokine modulation and the inhibition of co-stimulation. This review highlights the use of animal transplantation models to guide new therapeutic principles.
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Affiliation(s)
- Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Geoffrey R Hill
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Division of Medical Oncology, The University of Washington, Seattle, WA, United States
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15
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Friend BD, Schiller GJ. Beyond steroids: A systematic review and proposed solutions to managing acute graft-versus-host disease in adolescents and young adults. Blood Rev 2021; 52:100886. [PMID: 34509319 DOI: 10.1016/j.blre.2021.100886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022]
Abstract
The outcomes of allogeneic hematopoietic cell transplantation (HCT) in adolescents and young adults (AYAs) with hematologic malignancies have been shown to be poorer when compared to results in children, due to a combination of higher relapse rates and greater treatment-related mortality (TRM). Although differences in relapse risk have been studied extensively, toxicity has been examined and reported less often. In this systematic review, we summarize recently published studies that have examined the differences in rates of TRM and acute graft-versus-host disease (GVHD) in AYAs and children with hematologic malignancies, and attempt to explain why these disparities exist and how they impact outcomes. In addition, we present best practices for management of steroid-refractory GVHD that are likely to improve survival in this patient population. Further, we propose the development of personalized, risk-based approaches for the prevention and treatment of GVHD that incorporate novel platforms and interventions. We believe this individualized approach is likely to reduce toxicity and greatly improve outcomes for this vulnerable population.
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Affiliation(s)
- Brian D Friend
- Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Ave, Suite 1630, Houston, TX 77030, USA.
| | - Gary J Schiller
- Department of Medicine, Division of Hematology-Oncology, University of California Los Angeles, 10833 Le Conte Ave, 42-121 CHS, Los Angeles, CA 90095, USA.
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16
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Ibrahimova A, Davies SM, Lane A, Jordan MB, Lake K, Litts B, Chaturvedi V, Owsley E, Myers KC, Nelson AS, Mehta PA, Marsh RA, Khandelwal P. α4β7 Integrin expression and blockade in pediatric and young adult gastrointestinal graft-versus-host disease. Pediatr Blood Cancer 2021; 68:e28968. [PMID: 33861521 DOI: 10.1002/pbc.28968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/04/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND We hypothesized that α4β7 integrin expression on effector memory T cells (TEMs) would be elevated in pediatric hematopoietic stem cell transplant (HSCT) patients before and at diagnosis of acute gastrointestinal graft-versus-host disease (GI GVHD) symptoms compared to patients without GVHD, and that clinical blockade of α4β7 integrin with vedolizumab would be effective in pediatric GI GVHD. METHODS We analyzed surface expression of α4β7 integrin on T cells from 48 pediatric allogeneic HSCT recipients from our biorepository with known clinical outcomes as follows: acute GI GVHD (n = 22), isolated skin GVHD (n = 12), and no GVHD (n = 14). T-cell analyses were performed 1 week before and at GVHD diagnosis in patients with GVHD, and day +30 after HSCT in patients without GVHD. We describe clinical outcomes of seven additional patients, different from above-described 48 patients, who received vedolizumab (anti-α4β7 integrin antibody) for the treatment of steroid-refractory acute GI GVHD. RESULTS Expression of α4β7 integrin on CD8+ TEMs was upregulated in patients with GI GVHD compared to the no GI GVHD (skin GVHD + no GVHD) group 1 week prior to clinical symptoms (p = .02) and at acute GI GVHD diagnosis (p = .05). Four of seven treated patients with clinical steroid-refractory acute GI GVHD were evaluable for response to vedolizumab. One patient had a complete response at day +28, while two had a partial response, and one had no response. No adverse effects directly attributable to vedolizumab were observed. CONCLUSION Our data suggest a rationale for the blockade of α4β7 integrin for acute GI GVHD management in children.
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Affiliation(s)
- Azada Ibrahimova
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Stella M Davies
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Lane
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael B Jordan
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kelly Lake
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Bridget Litts
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vijaya Chaturvedi
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Erika Owsley
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kasiani C Myers
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam S Nelson
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Parinda A Mehta
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rebecca A Marsh
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Pooja Khandelwal
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
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17
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冯 小, 尧 捷, 吴 涯, 程 霞, 邹 坪, 王 华, 杨 牧. [Research and Application of Stem Cell-Based Therapy in Idiopathic Pulmonary Fibrosis: A Review]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2021; 52:373-379. [PMID: 34018353 PMCID: PMC10409213 DOI: 10.12182/20210560304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Indexed: 11/23/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a type of pulmonary disease that progresses acutely or slowly into irreversible pulmonary diseases, resulting in the end severe damages to patients' lung functions, as well as deaths. At present, the pathogenesis of pulmonary fibrosis is still not clear and there is no effective therapeutic measure available to control the progression of the disease. Research findings indicate that stem cells, being the origin of all cells of organisms, participate in the development of individuals at various stages and play an important role in repairing pulmonary tissue damage. Stem cells are attracting growing attention in the field of regenerative medicine, providing new ideas for treating IPF with transplanted stem cells. Herein, in order to better explore the potential applications of stem cell transplantation in treating IPF, we attempt to summarize preliminary studies of stem cell-mediated pulmonary remodeling after IPF, as well as cutting-edge clinical trials in stem cell-based IPF therapy.
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Affiliation(s)
- 小蓉 冯
- 电子科技大学医学院附属肿瘤医院 肿瘤基础转化研究中心 (成都 610041)Centre for Basic and Translational Research in Cancer, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu 610041, China
- 电子科技大学医学院 (成都 610041)School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China
| | - 捷 尧
- 电子科技大学医学院附属肿瘤医院 肿瘤基础转化研究中心 (成都 610041)Centre for Basic and Translational Research in Cancer, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu 610041, China
- 电子科技大学医学院 (成都 610041)School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China
| | - 涯 吴
- 电子科技大学医学院附属肿瘤医院 肿瘤基础转化研究中心 (成都 610041)Centre for Basic and Translational Research in Cancer, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu 610041, China
| | - 霞 程
- 电子科技大学医学院附属肿瘤医院 肿瘤基础转化研究中心 (成都 610041)Centre for Basic and Translational Research in Cancer, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu 610041, China
| | - 坪金 邹
- 电子科技大学医学院附属肿瘤医院 肿瘤基础转化研究中心 (成都 610041)Centre for Basic and Translational Research in Cancer, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu 610041, China
- 电子科技大学医学院 (成都 610041)School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China
| | - 华 王
- 电子科技大学医学院附属肿瘤医院 肿瘤基础转化研究中心 (成都 610041)Centre for Basic and Translational Research in Cancer, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu 610041, China
- 电子科技大学医学院 (成都 610041)School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China
| | - 牧 杨
- 电子科技大学医学院附属肿瘤医院 肿瘤基础转化研究中心 (成都 610041)Centre for Basic and Translational Research in Cancer, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu 610041, China
- 电子科技大学医学院 (成都 610041)School of Medicine, University of Electronic Science and Technology of China, Chengdu 610041, China
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18
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Abstract
Graft-vs. host disease (GVHD), both acute and chronic are among the chief non-relapse complications of allogeneic transplantation which still cause substantial morbidity and mortality despite significant advances in supportive care over the last few decades. The prevention of GVHD therefore remains critical to the success of allogeneic transplantation. In this review we briefly discuss the pathophysiology and immunobiology of GVHD and the current standards in the field which remain centered around calcineurin inhibitors. We then discuss important translational advances in GVHD prophylaxis, approaching these various platforms from a mechanistic standpoint based on the pathophysiology of GVHD including in-vivo and ex-vivo T-cell depletion alongwith methods of selective T-cell depletion, modulation of T-cell co-stimulatory pathways (checkpoints), enhancing regulatory T-cells (Tregs), targeting T-cell trafficking as well as cytokine pathways. Finally we highlight exciting novel pre-clinical research that has the potential to translate to the clinic successfully. We approach these methods from a pathophysiology based perspective as well and touch upon strategies targeting the interaction between tissue damage induced antigens and T-cells, regimen related endothelial toxicity, T-cell co-stimulatory pathways and other T-cell modulatory approaches, T-cell trafficking, and cytokine pathways. We end this review with a critical discussion of existing data and novel therapies that may be transformative in the field in the near future as a comprehensive picture of GVHD prophylaxis in 2020. While calcineurin inhibitors remain the standard, post-transplant eparinsphamide originally developed to facilitate haploidentical transplantation is becoming an attractive alternative to traditional calcinuerin inhibitor based prophylaxis due to its ability to reduce severe forms of acute and chronic GVHD without compromising other outcomes, even in the HLA-matched setting. In addition T-cell modulation, particularly targeting some important T-cell co-stimulatory pathways have resulted in promising outcomes and may be a part of GVHD prophylaxis in the future. Novel approaches including targeting early events in GVHD pathogenesis such as interactions bvetween tissue damage associated antigens and T-cells, endothelial toxicity, and T-cell trafficking are also promising and discussed in this review. GVHD prophylaxis in 2020 continues to evolve with novel exicitng therapies on the horizon based on a more sophisticated understanding of the immunobiology of GVHD.
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19
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Rozmus J. Monogenic Immune Diseases Provide Insights Into the Mechanisms and Treatment of Chronic Graft-Versus-Host Disease. Front Immunol 2021; 11:574569. [PMID: 33613511 PMCID: PMC7889949 DOI: 10.3389/fimmu.2020.574569] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 12/07/2020] [Indexed: 12/22/2022] Open
Abstract
Chronic graft-versus-host disease (GvHD) has become a leading cause of morbidity and mortality following allogeneic hematopoietic stem cell transplantation (HSCT) and can burden patients with devastating and lifelong health effects. Our understanding of the pathogenic mechanisms underlying chronic GvHD remains incomplete and this lack of understanding is reflected by lack of clear therapeutic approaches to steroid refractory disease. Observations predominantly from mouse models and human correlative studies currently support a three phase model for the initiation and development of chronic GvHD: 1) early inflammation and tissue damage triggers the innate immune system. This leads to inflammatory cytokine/chemokine patterns that recruit effector immune cell populations; 2) chronic inflammation causes the loss of central and peripheral tolerance mechanisms leading to emergence of pathogenic B and T cell populations that promote autoimmune and alloimmune reactions; 3) the dysregulated immunity causes altered macrophage polarization, aberrant tissue repair leading to scarring and end organ fibrosis. This model has led to the evaluation of many new therapies aimed at limiting inflammation, targeting dysregulated signaling pathways and restoring tolerance mechanisms. However, chronic GvHD is a multisystem disease with complex clinical phenotypes and it remains unclear as to which cluster of patients will respond best to specific therapeutic strategies. However, it is possible to gain novel insights from immune-related monogenic diseases. These diseases either share common clinical manifestations, replicate steps from the three phase chronic GvHD model or serve as surrogates for perfectly targeted drugs being investigated in chronic GvHD therapy. In this review, we will summarize the evidence from these monogenic immune related diseases that provide insight into pathogenic pathways in chronic GvHD, rationales for current therapies and novel directions for future drug discovery.
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Affiliation(s)
- Jacob Rozmus
- Division of Pediatric Hematology, Oncology & BMT, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada.,Michael Cuccione Childhood Cancer Research Program, BC Children's Hospital Research Institute, Vancouver, BC, Canada
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20
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Farag SS, Abu Zaid M, Schwartz JE, Thakrar TC, Blakley AJ, Abonour R, Robertson MJ, Broxmeyer HE, Zhang S. Dipeptidyl Peptidase 4 Inhibition for Prophylaxis of Acute Graft-versus-Host Disease. N Engl J Med 2021; 384:11-19. [PMID: 33406328 PMCID: PMC7845486 DOI: 10.1056/nejmoa2027372] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Dipeptidyl peptidase 4 (DPP-4; also known as CD26), a transmembrane receptor expressed on T cells, has a costimulatory function in activating T cells. In a mouse model, down-regulation of CD26 prevented graft-versus-host disease (GVHD) but preserved graft-versus-tumor effects. Whether inhibition of DPP-4 with sitagliptin may prevent acute GVHD after allogeneic stem-cell transplantation is not known. METHODS We conducted a two-stage, phase 2 clinical trial to test whether sitagliptin plus tacrolimus and sirolimus would reduce the incidence of grade II to IV acute GVHD from 30% to no more than 15% by day 100. Patients received myeloablative conditioning followed by mobilized peripheral-blood stem-cell transplants. Sitagliptin was given orally at a dose of 600 mg every 12 hours starting the day before transplantation until day 14 after transplantation. RESULTS A total of 36 patients who could be evaluated, with a median age of 46 years (range, 20 to 59), received transplants from matched related or unrelated donors. Acute GVHD occurred in 2 of 36 patients by day 100; the incidence of grade II to IV GVHD was 5% (95% confidence interval [CI], 1 to 16), and the incidence of grade III or IV GVHD was 3% (95% CI, 0 to 12). Nonrelapse mortality was zero at 1 year. The 1-year cumulative incidences of relapse and chronic GVHD were 26% (95% CI, 13 to 41) and 37% (95% CI, 22 to 53), respectively. GVHD-free, relapse-free survival was 46% (95% CI, 29 to 62) at 1 year. Toxic effects were similar to those seen in patients undergoing allogeneic stem-cell transplantation. CONCLUSIONS In this nonrandomized trial, sitagliptin in combination with tacrolimus and sirolimus resulted in a low incidence of grade II to IV acute GVHD by day 100 after myeloablative allogeneic hematopoietic stem-cell transplantation. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT02683525.).
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Affiliation(s)
- Sherif S Farag
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Mohammad Abu Zaid
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Jennifer E Schwartz
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Teresa C Thakrar
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Ann J Blakley
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Rafat Abonour
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Michael J Robertson
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Hal E Broxmeyer
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
| | - Shuhong Zhang
- From the Indiana University School of Medicine (S.S.F., M.A.Z., J.E.S., R.A., M.J.R., H.E.B., S.Z.), Indiana University Health (S.S.F., M.A.Z., J.E.S., T.C.T., R.A., M.J.R.), and Indiana University Simon Comprehensive Cancer Center (S.S.F., A.J.B., H.E.B.) - all in Indianapolis
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21
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Martinez-Cibrian N, Zeiser R, Perez-Simon JA. Graft-versus-host disease prophylaxis: Pathophysiology-based review on current approaches and future directions. Blood Rev 2020; 48:100792. [PMID: 33386151 DOI: 10.1016/j.blre.2020.100792] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/11/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
Graft-versus-host disease (GvHD) was first described in 1959, since then major efforts have been made in order to understand its physiopathology and animal models have played a key role. Three steps, involving different pathways, have been recognised in either acute and chronic GvHD, identifying them as two distinct entities. In order to reduce GvHD incidence and severity, prophylactic measures were added to transplant protocols. The combination of a calcineurin inhibitor (CNI) plus an antimetabolite remains the standard of care. Better knowledge of GvHD pathophysiology has moved this field forward and nowadays different drugs are being used on a daily basis. Improving GvHD prophylaxis is a major goal as it would translate into less non-relapse mortality and better overall survival. As compared to CNI plus methotrexate the combination of CNI plus mycophenolate mophetil (MMF) allows us to obtain similar results in terms of GvHD incidence but a lower toxicity rate in terms of neutropenia or mucositis. The use of ATG has been related to a lower risk of acute and chronic GvHD in prospective randomized trials as well as the use of posttransplant Cyclophosphamide, with no or marginal impact on overall survival but with an improvement in GvHD-relapse free survival (GRFS). The use of sirolimus has been related to a lower risk of acute GvHD and significantly influenced overall survival in one prospective randomized trial. Other prospective trials have evaluated the use of receptors such as CCR5 or α4β7 to avoid T-cells trafficking into GvHD target organs, cytokine blockers or immune check point agonists. Also, epigenetic modifiers have shown promising results in phase II trials. Attention should be paid to graft-versus-leukemia, infections and immune recovery before bringing new prophylactic strategies to clinical practice. Although the list of novel agents for GvHD prophylaxis is growing, randomized trials are still lacking for many of them.
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Affiliation(s)
- Nuria Martinez-Cibrian
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain
| | - Robert Zeiser
- Department of Hematology, Oncology, and Stem Cell Transplantation, Faculty of Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Jose A Perez-Simon
- Department of Hematology, University Hospital Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), Universidad de Sevilla, Spain.
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22
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Vandenhove B, Canti L, Schoemans H, Beguin Y, Baron F, Graux C, Kerre T, Servais S. How to Make an Immune System and a Foreign Host Quickly Cohabit in Peace? The Challenge of Acute Graft- Versus-Host Disease Prevention After Allogeneic Hematopoietic Cell Transplantation. Front Immunol 2020; 11:583564. [PMID: 33193397 PMCID: PMC7609863 DOI: 10.3389/fimmu.2020.583564] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/21/2020] [Indexed: 01/16/2023] Open
Abstract
Allogeneic hematopoietic cell transplantation (alloHCT) has been used as cellular immunotherapy against hematological cancers for more than six decades. Its therapeutic efficacy relies on the cytoreductive effects of the conditioning regimen but also on potent graft-versus-tumor (GVT) reactions mediated by donor-derived immune cells. However, beneficial GVT effects may be counterbalanced by acute GVHD (aGVHD), a systemic syndrome in which donor immune cells attack healthy tissues of the recipient, resulting in severe inflammatory lesions mainly of the skin, gut, and liver. Despite standard prophylaxis regimens, aGVHD still occurs in approximately 20–50% of alloHCT recipients and remains a leading cause of transplant-related mortality. Over the past two decades, advances in the understanding its pathophysiology have helped to redefine aGVHD reactions and clinical presentations as well as developing novel strategies to optimize its prevention. In this review, we provide a brief overview of current knowledge on aGVHD immunopathology and discuss current approaches and novel strategies being developed and evaluated in clinical trials for aGVHD prevention. Optimal prophylaxis of aGVHD would prevent the development of clinically significant aGVHD, while preserving sufficient immune responsiveness to maintain beneficial GVT effects and immune defenses against pathogens.
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Affiliation(s)
- Benoît Vandenhove
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium
| | - Lorenzo Canti
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium
| | - Hélène Schoemans
- Department of Clinical Hematology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Yves Beguin
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium.,Department of Clinical Hematology, CHU of Liège, University of Liège, Liège, Belgium
| | - Frédéric Baron
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium.,Department of Clinical Hematology, CHU of Liège, University of Liège, Liège, Belgium
| | - Carlos Graux
- Department of Clinical Hematology, CHU UCL Namur (Godinne), Université Catholique de Louvain, Yvoir, Belgium
| | - Tessa Kerre
- Hematology Department, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Sophie Servais
- Laboratory of Hematology, GIGA-I3, GIGA Institute, University of Liège, Liège, Belgium.,Department of Clinical Hematology, CHU of Liège, University of Liège, Liège, Belgium
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23
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Phase II trial of natalizumab with corticosteroids as initial treatment of gastrointestinal acute graft-versus-host disease. Bone Marrow Transplant 2020; 56:1006-1012. [PMID: 32895491 DOI: 10.1038/s41409-020-01049-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022]
Abstract
The α4ß7 integrin is upregulated on naive and memory T cell subsets in patients who subsequently develop gastrointestinal (GI) acute GVHD. Natalizumab (Tysabri®, Biogen Inc.) acts against the α4 subunit that mediates homing of lymphocytes to the GI tract. We initiated a phase II study of natalizumab with corticosteroids for initial treatment of acute GI GVHD. In total, 300 mg IV of natalizumab was given, with steroids initiated up to 3 days prior. Twenty-one subjects were treated, median age was 63 years (range 38-74), and 15 (71%) were male. Eighteen (86%) underwent RIC, 15 (71%) received MUD, and all received PBSCs. Overall GVHD at enrollment was grade II in 4 and grade III in 17. The primary endpoint, day 56 GVHD-free survival rate, was attained in 33.3%. The overall response rate at day 28 and 56 was 57% and 52%, respectively. Six of eight CRs were durable for 1 year. Five experienced toxicity possibly related to natalizumab and ten had infections before day 100. 2-year OS was 43% (95% CI 22-62%) and 2-year NRM was 52% (95% CI 29-71%). Natalizumab with corticosteroids as initial treatment of acute GI GVHD is safe, effective, and durable.
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24
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Pai V, Abu-Arja R, Auletta JJ, Rangarajan HG. Successful treatment of steroid-refractory gastrointestinal acute graft-versus-host disease with adjuvant vedolizumab therapy in a pediatric allogeneic stem cell transplant recipient. Pediatr Blood Cancer 2020; 67:e28298. [PMID: 32472970 DOI: 10.1002/pbc.28298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 02/29/2020] [Accepted: 03/16/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Vinita Pai
- College of Pharmacy, The Ohio State University, Columbus, Ohio.,Pharmacy Department, Nationwide Children's Hospital, Columbus, Ohio
| | - Rolla Abu-Arja
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jeffery J Auletta
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Hemalatha G Rangarajan
- Division of Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
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25
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DiMaggio E. Acute Graft-versus-Host Disease: Emerging Insights and Updates into Detection, Prevention, and Treatment. Pharmacotherapy 2020; 40:788-807. [PMID: 32530080 DOI: 10.1002/phar.2436] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute graft-versus-host disease remains a devastating complication following hematopoietic cell transplantation, resulting in increased morbidity and mortality. Vast research efforts continue to refine or develop new means of prediction, assessment, prevention, and treatment of this syndrome. Recent updates in acute graft-versus-host disease include more definitive guidance and definitions for its grading and diagnosis. Biomarker use is being incorporated into early stages following hematopoietic cell transplantation to aid in the detection and prediction of long-term outcomes. New preventive strategies under investigation include the use of vedolizumab or tocilizumab as upfront prophylaxis. Finally, although steroids remain the backbone of therapy once treatment is warranted, the efficacy of several agents including vedolizumab, tocilizumab, ruxolitinib, and α1 antitrypsin are being evaluated as potential therapeutic options.
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26
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Shapiro RM, Antin JH. Therapeutic options for steroid-refractory acute and chronic GVHD: an evolving landscape. Expert Rev Hematol 2020; 13:519-532. [PMID: 32249631 DOI: 10.1080/17474086.2020.1752175] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: The traditional therapeutic modalities to manage SR-acute GVHD have focused on the inhibition of the alloreactive T-cell response, while in the setting of SR-chronic GVHD the focus has been on a combination of T-cell and B-cell targeting strategies. However, new therapeutic modalities have shown promise. The purpose of this review is to summarize the current treatment landscape of SR-acute and chronic GVHD.Areas covered: A systematic search of MEDLINE, EMBASE, and clinicaltrials.gov databases for published articles, abstracts, and clinical trials pertaining to available therapeutic modalities for SR-acute and SR-chronic GVHD was conducted. Also highlighted is a number of ongoing clinical trials in both SR-acute and SR-chronic GVHD with strategies targeting the JAK-1/2 pathway, the Treg:Tcon ratio, the immunomodulation mediated by mesenchymal stem cells, and the gut microbiome, among others. Expert opinion: Ruxolitinib has emerged as the preferred therapeutic modality for SR-acute GVHD, with alpha-1-antitrypsin and extracorporeal photophoresis (ECP) being reasonable alternatives. Ruxolitinib and Ibrutinib are among the preferred options for SR-chronic GVHD, with ECP being a viable alternative particularly if the skin is involved. A number of novel therapeutic modalities, including those enhancing the activity of regulatory T-cells have shown great promise in early phase trials of SR-chronic GVHD.
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Affiliation(s)
- Roman M Shapiro
- Advanced Fellow in Stem Cell Transplantation, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Joseph H Antin
- Blood and Marrow Transplantation Program, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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