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Youngster I, Eshel A, Geva M, Danylesko I, Henig I, Zuckerman T, Fried S, Yerushalmi R, Shem-Tov N, Fein JA, Bomze D, Shimoni A, Koren O, Shouval R, Nagler A. Fecal microbiota transplantation in capsules for the treatment of steroid refractory and steroid dependent acute graft vs. host disease: a pilot study. Bone Marrow Transplant 2024; 59:409-416. [PMID: 38212672 DOI: 10.1038/s41409-024-02198-2] [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: 09/26/2023] [Revised: 12/21/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024]
Abstract
Acute graft-versus-host disease (aGvHD) is a serious complication of allogeneic hematopoietic stem-cell transplantation with limited treatment options. The gut microbiome plays a critical role in aGvHD pathogenesis. Fecal microbiota transplantation (FMT) has emerged as a potential therapeutic approach to restore gut microbial diversity. In this prospective pilot study, 21 patients with steroid-resistant or steroid-dependent lower gastrointestinal aGvHD received FMT in capsule form. At 28 days after the first FMT, the overall response rate was 52.4%, with 23.8% complete and 28.6% partial responses. However, sustained responses were infrequent, with only one patient remaining aGvHD-free long-term. FMT was generally well-tolerated. Microbiome analysis revealed dysbiosis in pre-FMT patient stool samples, with distinct microbial characteristics compared to donors. Following FMT, there was an increase in beneficial Clostridiales and a decrease in pathogenic Enterobacteriales. These findings highlight the potential of FMT as a treatment option for steroid-resistant aGvHD. Trial registration number NCT #03214289.
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Affiliation(s)
- Ilan Youngster
- Shamir Medical Center, Beer Yaacov, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Eshel
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Mika Geva
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Ivetta Danylesko
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Israel Henig
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Shalev Fried
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Ronit Yerushalmi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Noga Shem-Tov
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Joshua A Fein
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - David Bomze
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Division of Dermatology, Sourasky Medical Center, Tel Aviv, Israel
| | - Avichai Shimoni
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
| | - Omry Koren
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Roni Shouval
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel.
- Adult BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Weill Cornell Medical College, New York, NY, USA.
| | - Arnon Nagler
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel Hashomer, Tel Aviv, Israel
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Yue X, Zhou H, Wang S, Chen X, Xiao H. Gut microbiota, microbiota-derived metabolites, and graft-versus-host disease. Cancer Med 2024; 13:e6799. [PMID: 38239049 PMCID: PMC10905340 DOI: 10.1002/cam4.6799] [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: 08/21/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 03/02/2024] Open
Abstract
Allogeneic hematopoietic stem cell transplantation is one of the most effective treatment strategies for leukemia, lymphoma, and other hematologic malignancies. However, graft-versus-host disease (GVHD) can significantly reduce the survival rate and quality of life of patients after transplantation, and is therefore the greatest obstacle to transplantation. The recent development of new technologies, including high-throughput sequencing, metabolomics, and others, has facilitated great progress in understanding the complex interactions between gut microbiota, microbiota-derived metabolites, and the host. Of these interactions, the relationship between gut microbiota, microbial-associated metabolites, and GVHD has been most intensively researched. Studies have shown that GVHD patients often suffer from gut microbiota dysbiosis, which mainly manifests as decreased microbial diversity and changes in microbial composition and microbiota-derived metabolites, both of which are significant predictors of poor prognosis in GVHD patients. Therefore, the purpose of this review is to summarize what is known regarding changes in gut microbiota and microbiota-derived metabolites in GVHD, their relationship to GVHD prognosis, and corresponding clinical strategies designed to prevent microbial dysregulation and facilitate treatment of GVHD.
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Affiliation(s)
- XiaoYan Yue
- Department of Hematology, Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouChina
| | - Hongyu Zhou
- Department of Hematology, Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouChina
| | - ShuFen Wang
- Department of Hematology, Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouChina
| | - Xu Chen
- Department of Hematology, Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouChina
| | - HaoWen Xiao
- Department of Hematology, Sir Run Run Shaw HospitalZhejiang University School of MedicineHangzhouChina
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Cho NA, Strayer K, Dobson B, McDonald B. Pathogenesis and therapeutic opportunities of gut microbiome dysbiosis in critical illness. Gut Microbes 2024; 16:2351478. [PMID: 38780485 PMCID: PMC11123462 DOI: 10.1080/19490976.2024.2351478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
For many years, it has been hypothesized that pathological changes to the gut microbiome in critical illness is a driver of infections, organ dysfunction, and other adverse outcomes in the intensive care unit (ICU). The advent of contemporary microbiome methodologies and multi-omics tools have allowed researchers to test this hypothesis by dissecting host-microbe interactions in the gut to better define its contribution to critical illness pathogenesis. Observational studies of patients in ICUs have revealed that gut microbial communities are profoundly altered in critical illness, characterized by markedly reduced alpha diversity, loss of commensal taxa, and expansion of potential pathogens. These key features of ICU gut dysbiosis have been associated with adverse outcomes including life-threatening hospital-acquired (nosocomial) infections. Current research strives to define cellular and molecular mechanisms connecting gut dysbiosis with infections and other outcomes, and to identify opportunities for therapeutic modulation of host-microbe interactions. This review synthesizes evidence from studies of critically ill patients that have informed our understanding of intestinal dysbiosis in the ICU, mechanisms linking dysbiosis to infections and other adverse outcomes, as well as clinical trials of microbiota-modifying therapies. Additionally, we discuss novel avenues for precision microbial therapeutics to combat nosocomial infections and other life-threatening complications of critical illness.
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Affiliation(s)
- Nicole A Cho
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kathryn Strayer
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Breenna Dobson
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Rashidi A, Ebadi M, Rehman TU, Elhusseini H, Kazadi D, Halaweish H, Khan MH, Hoeschen A, Cao Q, Luo X, Kabage AJ, Lopez S, Holtan SG, Weisdorf DJ, Khoruts A, Staley C. Randomized Double-Blind Phase II Trial of Fecal Microbiota Transplantation Versus Placebo in Allogeneic Hematopoietic Cell Transplantation and AML. J Clin Oncol 2023; 41:5306-5319. [PMID: 37235836 PMCID: PMC10691796 DOI: 10.1200/jco.22.02366] [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: 10/24/2022] [Revised: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
PURPOSE Gut microbiota injury in allogeneic hematopoietic cell transplantation (HCT) recipients and patients with AML has been associated with adverse clinical outcomes. Previous studies in these patients have shown improvements in various microbiome indices after fecal microbiota transplantation (FMT). However, whether microbiome improvements translate into improved clinical outcomes remains unclear. We examined this question in a randomized, double-blind, placebo-controlled phase II trial. METHODS Two independent cohorts of allogeneic HCT recipients and patients with AML receiving induction chemotherapy were randomly assigned in a 2:1 ratio to receive standardized oral encapsulated FMT versus placebo upon neutrophil recovery. After each course of antibacterial antibiotics, patients received a study treatment. Up to three treatments were administered within 3 months. The primary end point was 4-month all-cause infection rate. Patients were followed for 9 months. RESULTS In the HCT cohort (74 patients), 4-month infection density was 0.74 and 0.91 events per 100 patient-days in FMT and placebo arms, respectively (infection rate ratio, 0.83; 95% CI, 0.48 to 1.42; P = .49). In the AML cohort (26 patients), 4-month infection density was 0.93 in the FMT arm and 1.25 in the placebo arm, with an infection rate ratio of 0.74 (95% CI, 0.32 to 1.71; P = .48). Unique donor bacterial sequences comprised 25%-30% of the fecal microbiota after FMT. FMT improved postantibiotic recovery of microbiota diversity, restored several depleted obligate anaerobic commensals, and reduced the abundance of expanded genera Enterococcus, Streptococcus, Veillonella, and Dialister. CONCLUSION In allogeneic HCT recipients and patients with AML, third-party FMT was safe and ameliorated intestinal dysbiosis, but did not decrease infections. Novel findings from this trial will inform future development of FMT trials.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
- Clinical Research Division, Fred Hutchinson Cancer Center; and Division of Oncology, University of Washington, Seattle, WA
| | - Maryam Ebadi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Tauseef Ur Rehman
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Heba Elhusseini
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - David Kazadi
- Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | | | - Andrea Hoeschen
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Qing Cao
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Xianghua Luo
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - Sharon Lopez
- Center for Immunology, University of Minnesota, Minneapolis, MN
| | - Shernan G. Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Daniel J. Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Alexander Khoruts
- Center for Immunology, University of Minnesota, Minneapolis, MN
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Minnesota, Minneapolis, MN
- Biotechnology Institute, University of Minnesota, St Paul, MN
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Shtossel O, Turjeman S, Riumin A, Goldberg MR, Elizur A, Bekor Y, Mor H, Koren O, Louzoun Y. Recipient-independent, high-accuracy FMT-response prediction and optimization in mice and humans. MICROBIOME 2023; 11:181. [PMID: 37580821 PMCID: PMC10424414 DOI: 10.1186/s40168-023-01623-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 07/14/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Some microbiota compositions are associated with negative outcomes, including among others, obesity, allergies, and the failure to respond to treatment. Microbiota manipulation or supplementation can restore a community associated with a healthy condition. Such interventions are typically probiotics or fecal microbiota transplantation (FMT). FMT donor selection is currently based on donor phenotype, rather than the anticipated microbiota composition in the recipient and associated health benefits. However, the donor and post-transplant recipient conditions differ drastically. We here propose an algorithm to identify ideal donors and predict the expected outcome of FMT based on donor microbiome alone. We also demonstrate how to optimize FMT for different required outcomes. RESULTS We show, using multiple microbiome properties, that donor and post-transplant recipient microbiota differ widely and propose a tool to predict the recipient post-transplant condition (engraftment success and clinical outcome), using only the donors' microbiome and, when available, demographics for transplantations from humans to either mice or other humans (with or without antibiotic pre-treatment). We validated the predictor using a de novo FMT experiment highlighting the possibility of choosing transplants that optimize an array of required goals. We then extend the method to characterize a best-planned transplant (bacterial cocktail) by combining the predictor and a generative genetic algorithm (GA). We further show that a limited number of taxa is enough for an FMT to produce a desired microbiome or phenotype. CONCLUSIONS Off-the-shelf FMT requires recipient-independent optimized FMT selection. Such a transplant can be from an optimal donor or from a cultured set of microbes. We have here shown the feasibility of both types of manipulations in mouse and human recipients. Video Abstract.
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Affiliation(s)
- Oshrit Shtossel
- Department of Mathematics, Bar-Ilan University, Ramat Gan, 52900, Israel.
| | - Sondra Turjeman
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Alona Riumin
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Michael R Goldberg
- Yitzhak Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Arnon Elizur
- Yitzhak Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv, Israel
| | - Yarin Bekor
- Department of Mathematics, Bar-Ilan University, Ramat Gan, 52900, Israel
| | - Hadar Mor
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Omry Koren
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Yoram Louzoun
- Department of Mathematics, Bar-Ilan University, Ramat Gan, 52900, Israel.
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Asokan S, Cullin N, Stein-Thoeringer CK, Elinav E. CAR-T Cell Therapy and the Gut Microbiota. Cancers (Basel) 2023; 15:cancers15030794. [PMID: 36765752 PMCID: PMC9913364 DOI: 10.3390/cancers15030794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/03/2023] Open
Abstract
Chimeric antigen receptor (CAR) - T cell cancer therapy has yielded promising results in treating hematologic malignancies in clinical studies, and a growing number of CAR-T regimens are approved for clinical usage. While the therapy is considered of great potential in expanding the cancer immunotherapy arsenal, more than half of patients receiving CAR-T infusions do not respond, while others develop significant adverse effects, collectively indicating a need for optimization of CAR-T treatment to the individual. The microbiota is increasingly suggested as a major modulator of immunotherapy responsiveness. Studying causal microbiota roles possibly contributing to CAR-T therapy efficacy, adverse effects reduction, and prediction of patient responsiveness constitutes an exciting area of active research. Herein, we discuss the latest developments implicating human microbiota involvement in CAR-T therapy, while highlighting challenges and promises in harnessing the microbiota as a predictor and modifier of CAR-T treatment towards optimized efficacy and minimization of treatment-related adverse effects.
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Affiliation(s)
- Sahana Asokan
- Division of Microbiome and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Faculty of Biosciences, Heidelberg University, 69120 Heidelberg, Germany
| | - Nyssa Cullin
- Division of Microbiome and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Christoph K. Stein-Thoeringer
- Department of Internal Medicine I, Laboratory of Translational Microbiome Science, University Clinic Tuebingen, Otfried-Mueller-Strasse 10, 72076 Tuebingen, Germany
- Correspondence: (C.K.S-T.); (E.E.); Tel.: +972-8-9344014 (E.E.)
| | - Eran Elinav
- Division of Microbiome and Cancer, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
- Systems Immunology Department, Weizmann Institute of Science, 234 Herzl Street, Rehovot 7610001, Israel
- Correspondence: (C.K.S-T.); (E.E.); Tel.: +972-8-9344014 (E.E.)
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Turjeman S, Koren O. Using the microbiome in clinical practice. Microb Biotechnol 2022; 15:129-134. [PMID: 34767683 PMCID: PMC8719822 DOI: 10.1111/1751-7915.13971] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 10/31/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Omry Koren
- Azrieli Faculty of MedicineBar‐Ilan UniversitySafedIsrael
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8
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Martini DJ, Chen YB, DeFilipp Z. OUP accepted manuscript. Oncologist 2022; 27:685-693. [PMID: 35443042 PMCID: PMC9355804 DOI: 10.1093/oncolo/oyac076] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/17/2022] [Indexed: 11/29/2022] Open
Abstract
Graft-versus-host disease (GVHD) is a common complication of allogeneic hematopoietic cell transplantation (HCT) and is associated with significant morbidity and mortality. For many years, there have been few effective treatment options for patients with GVHD. First-line systemic treatment remains corticosteroids, but up to 50% of patients will develop steroid-refractory GVHD and the prognosis for these patients is poor. Elucidation of the pathophysiological mechanisms of acute and chronic GVHD has laid a foundation for novel therapeutic approaches. Since 2017, there have now been 4 approvals by the US Food and Drug Administration (FDA) for GVHD. Ruxolitinib, an oral selective JAK1/2 inhibitor, received FDA approval for the treatment of steroid-refractory acute GVHD in 2019 and remains the only agent approved for acute GVHD. There are currently 3 FDA approvals for the treatment of chronic GVHD: (1) ibrutinib, a BTK inhibitor traditionally used for B-cell malignancies, was the first agent approved for chronic GVHD after failure of one or more lines of systemic therapy, (2) belumosudil, an oral selective inhibitor of ROCK2, for patients with chronic GVHD who received at least 2 prior lines of treatment, and (3) ruxolitinib for chronic GVHD after failure of one or two lines of systemic therapy. In this review, we highlight the clinical data which support these FDA approvals in acute and chronic GVHD with a focus on mechanism of actions, clinical efficacy, and toxicities associated with these agents.
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Affiliation(s)
- Dylan J Martini
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA, USA
| | - Zachariah DeFilipp
- Corresponding author: Zachariah DeFilipp, MD, 55 Fruit Street, Zero Emerson Place, Suite 118, Office 134, Boston, USA. Tel: +1 617-726-5765; Fax: +1 617-643-5843;
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