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Murray A, Linn SM, Yu B, Novitzky-Basso I, Mattsson J, Kennah M, Elemary M, White J, Lemieux C, Jamani K, Kim DDH. Real-world experience with ruxolitinib therapy for steroid-refractory acute graft versus host disease. Bone Marrow Transplant 2024; 59:759-764. [PMID: 38402344 DOI: 10.1038/s41409-024-02249-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 01/12/2024] [Accepted: 02/12/2024] [Indexed: 02/26/2024]
Abstract
Acute graft versus host disease (aGVHD) is a complication of allogeneic hematopoietic stem cell transplant (HCT) and is associated with significant morbidity and mortality. Steroid refractory aGVHD (SR-aGVHD) carries a particularly grim prognosis. Ruxolitinib has shown promise for treatment of SR-aGVHD in a phase 3 trial; however, safety and efficacy data outside of the clinical trial setting is lacking. We performed a multicenter retrospective study to examine the response to ruxolitinib and its efficacy in patients with SR-aGVHD. We included 59 patients treated with ruxolitinib for SR-aGVHD between 2015 and 2022. Of these 59 patients, 36 patients (61.0%) achieved a complete (CR) or partial response (PR) at 28 days, while 31 patients (52.5%) obtained a CR/PR at day 56. Patients that achieved a CR or PR at day 28 had a higher rate of overall survival (OS; 69.2%), compared with patients that did not (31.6%; p = 0.037). OS at 12 months was 41.5%, with a median OS duration of 5.3 months. Failure free survival (FFS) at 12 months was 29.1%, with a median FFS of 2.6 months. Overall, this real-world experience data support ruxolitinib as the standard of care for SR-aGVHD in a non-controlled trial population.
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Affiliation(s)
- Alistair Murray
- Division of Hematology and Hematologic Malignancies, University of Calgary, Calgary, AB, Canada
| | - Swe Mar Linn
- Hans Messner Allogeneic Blood and Marrow Transplant Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Benoit Yu
- Laval University, Quebec City, QC, Canada
| | - Igor Novitzky-Basso
- Hans Messner Allogeneic Blood and Marrow Transplant Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Hematology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jonas Mattsson
- Hans Messner Allogeneic Blood and Marrow Transplant Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada
- Department of Hematology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael Kennah
- Department of Hematology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mohamed Elemary
- University of Saskatchewan, Saskatoon, SK, Canada
- Saskatchewan Cancer Agency, Saskatoon, SK, Canada
| | - Jennifer White
- The Leukemia/Bone Marrow Transplant Program, Vancouver General Hospital, British Columbia Cancer Agency, Vancouver, BC, Canada
- University of British Columbia, Columbia, BC, Canada
| | - Christopher Lemieux
- Laval University, Quebec City, QC, Canada
- Division of Hematology and Medical Oncology, CHU de Québec -Université Laval, Quebec City, QC, Canada
| | - Kareem Jamani
- Division of Hematology and Hematologic Malignancies, University of Calgary, Calgary, AB, Canada
- Alberta Blood & Marrow Transplant Program, Tom-Baker Cancer Centre, Calgary, AB, Canada
| | - Dennis Dong Hwan Kim
- Hans Messner Allogeneic Blood and Marrow Transplant Unit, Princess Margaret Cancer Centre, Toronto, ON, Canada.
- Department of Hematology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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2
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Sala E, Neagoie AM, Lewerenz J, Saadati M, Benner A, Gantner A, Wais V, Döhner H, Bunjes D. Neurologic Complications of the Central Nervous System after Allogeneic Stem Cell Transplantation: The Role of Transplantation-Associated Thrombotic Microangiopathy as a Potential Underreported Cause. Transplant Cell Ther 2024; 30:586.e1-586.e11. [PMID: 38508452 DOI: 10.1016/j.jtct.2024.03.017] [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: 01/31/2024] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 03/22/2024]
Abstract
Neurologic complications (NCs), especially those of the central nervous system (CNS), represent a severe complication after allogeneic stem cell transplantation (allo-HSCT) and are associated with relevant morbidity and mortality. We aimed to characterize the potential risk factors for the development of CNS-NC, with a special focus on the role of calcineurin inhibitors (CNIs) as a predisposing factor. For this purpose, we compared cyclosporin A (CsA) versus tacrolimus (TAC) with respect to their influence on the incidence and type of CNS-NC after allo-HSCT. We retrospectively analyzed the incidence, risk factors, and impact on outcomes of CNS-NC diagnosed during the post-transplantation follow-up in patients with different high-risk hematologic malignancies who underwent allo-HSCT at our institution over a 20-year period. All patients included in the analysis received CNI (CsA or TAC) as graft-versus-host disease (GVHD) prophylaxis. We evaluated a total of 739 consecutive patients who underwent transplantation between December 1999 and April 2019. During a median follow-up of 6.8 years, we observed a CNS-NC incidence of 17%. The development of CNS-NC was associated with decreased overall survival (OS) and increased transplantation-related mortality (TRM). The most frequent CNS-NCs were infections (30%) and neurologic adverse events related to the administration of CNI, TAC, or CsA as GVHD prophylaxis (42%). In the multivariable analysis, age, total body irradiation (TBI), and severe acute GVHD and chronic GVHD were significant risk factors in the development of CNS-NCs. TAC compared with CsA emerged as an independent predisposing factor for CNS-NCs. The TAC-associated risk of CNS-NCs was related mostly to the occurrence of transplantation-associated thrombotic microangiopathy (TA-TMA) with neurologic manifestations (neuro-TA-TMA), although the general TA-TMA incidence was comparable in the 2 CNI subgroups. CNS-NCs are associated with poor prognosis after allo-HSCT, with TAC emerging as a potential yet insufficiently characterized predisposing factor.
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Affiliation(s)
- Elisa Sala
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany.
| | - Adela M Neagoie
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Jan Lewerenz
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Maral Saadati
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andrea Gantner
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Verena Wais
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
| | - Donald Bunjes
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
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3
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DeFilipp Z, Damania AV, Kim HT, Chang CC, El-Jawahri A, McAfee SL, Bottoms AJS, Toncheva V, Smith MM, Dolaher M, Perry L, White M, Diana B, Connolly S, Dey BR, Frigault MJ, Newcomb RA, O’Donnell PV, Spitzer TR, Mansour MK, Weber D, Ajami NJ, Hohmann E, Jenq RR, Chen YB. Third-party fecal microbiota transplantation for high-risk treatment-naïve acute GVHD of the lower GI tract. Blood Adv 2024; 8:2074-2084. [PMID: 38471063 PMCID: PMC11063394 DOI: 10.1182/bloodadvances.2024012556] [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: 01/02/2024] [Revised: 03/01/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
ABSTRACT Disruption of the intestinal microbiome is observed with acute graft-versus-host disease (GVHD) of the lower gastrointestinal (LGI) tract, and fecal microbiota transplantation (FMT) has successfully cured steroid-refractory cases. In this open-label, single-arm, pilot study, third-party, single-donor FMT was administered in combination with systemic corticosteroids to participants with high-risk acute LGI GVHD, with a focus on treatment-naïve cases. Participants were scheduled to receive 1 induction dose (15 capsules per day for 2 consecutive days), followed by 3 weekly maintenance doses, consisting of 15 capsules per dose. The primary end point of the study was feasibility, which would be achieved if ≥80% of participants able to swallow ≥40 of the 75 scheduled capsules. Ten participants (9 treatment-naïve; 1 steroid-refractory) were enrolled and treated. The study met the primary end point, with 9 of 10 participants completing all eligible doses. Organ-specific LGI complete response rate at day 28 was 70%. Initial clinical response was observed within 1 week for all responders, and clinical responses were durable without recurrent LGI GVHD in complete responders. Exploratory analyses suggest that alpha diversity increased after FMT. Although recipient microbiome composition never achieved a high degree of donor similarity, expansion of donor-derived species and increases in tryptophan metabolites and short-chain fatty acids were observed within the first 7 days after FMT. Investigation into the use of microbiome-targeted interventions earlier in the treatment paradigm for acute LGI GVHD is warranted. This trial was registered at www.ClinicalTrials.gov as #NCT04139577.
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Affiliation(s)
- Zachariah DeFilipp
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Ashish V. Damania
- Platform for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Haesook T. Kim
- Department of Data Science, Dana-Farber Cancer Institute and Harvard T. H. Chan School of Public Health, Boston, MA
| | - Chia-Chi Chang
- Platform for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Areej El-Jawahri
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Steven L. McAfee
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - AJ S. Bottoms
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Vesselina Toncheva
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Melissa M. Smith
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Maria Dolaher
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Lindsey Perry
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Meghan White
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Brittany Diana
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Sheila Connolly
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Bimalangshu R. Dey
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Matthew J. Frigault
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Richard A. Newcomb
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Paul V. O’Donnell
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Thomas R. Spitzer
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | - Michael K. Mansour
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | - Daniela Weber
- Departments of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nadim J. Ajami
- Platform for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elizabeth Hohmann
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA
| | - Robert R. Jenq
- Platform for Innovative Microbiome and Translational Research, Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
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Michonneau D, Devillier R, Keränen M, Rubio MT, Nicklasson M, Labussière-Wallet H, Carre M, Huynh A, Viayna E, Roset M, Finzi J, Pfeiffer M, Thunström D, Lara N, Sabatelli L, Chevallier P, Itälä-Remes M. Treatment Patterns and Clinical Outcomes of Patients with Moderate to Severe Acute Graft-Versus-Host Disease: A Multicenter Chart Review Study. Hematol Rep 2024; 16:283-294. [PMID: 38804281 PMCID: PMC11130792 DOI: 10.3390/hematolrep16020028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/14/2024] [Accepted: 04/11/2024] [Indexed: 05/29/2024] Open
Abstract
Acute graft-versus-host disease (aGVHD) remains a barrier to successful allogeneic hematopoietic stem cell transplantation (HSCT) outcomes. Contemporary comprehensive analyses of real-world clinical outcomes among patients who develop aGVHD post-HSCT are needed to better understand the unmet needs of this patient population. This multicenter, retrospective chart review describes treatment patterns and clinical outcomes among patients (≥18 years old) from Finland, Sweden, and France who developed grades II-IV aGVHD after their first HSCT (January 2016-June 2017). From 13 participating centers, 151 patients were included. The median (Q1, Q3) age at HSCT was 56 (45, 62) years old. One line of aGVHD treatment was received by 47.7%, and the most common first-line treatment was methylprednisolone (alone or in a combination regimen, 74.2%; monotherapy, 25.8%). Among patients treated with methylprednisolone, 79.5% achieved a complete or partial response. The median (Q1, Q3) number of treatment lines was 2.0 (1.0, 3.0). The median (Q1, Q3) time to obtain an aGVHD diagnosis from transplant was 29.5 (21.0, 44.0) days, and 14.5 (7.0, 34.0) days to achieve the best response for 110 evaluable patients. At 6 and 12 months, 53.6% and 49.0%, respectively, achieved a complete response. Chronic GVHD occurred in 37.7% of patients, and aGVHD reoccurred in 26.5%. Following aGVHD diagnosis, mortality rates were 30.0% at 6 months and 37.3% at 12 months. Findings from this study demonstrate a continuing unmet need for new therapies that control aGVHD and improve mortality.
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Affiliation(s)
- David Michonneau
- Hôpital Saint-Louis, Université de Paris, 1 Av. Claude Vellefaux, 75010 Paris, France
| | - Raynier Devillier
- Institute Paoli-Calmettes, 232 Boulevard de Sainte-Marguerite, 13009 Marseille, France
| | - Mikko Keränen
- Helsinki University Hospital, Yliopistonkatu 3, P.O. Box 4, 00014 Helsinki, Finland
| | - Marie Thérèse Rubio
- Service d’Hématologie, Hôpital Brabois, Centre Hospitalier Régional Universitaire Nancy, Rue du Morvan, 54511 Vandoeuvre-les-Nancy, France
| | - Malin Nicklasson
- Section of Hematology and Coagulation, Department of Specialist Medicine, Sahlgrenska University Hospital, 413 46 Gothenburg, Sweden
| | | | - Martin Carre
- Centre Hospitalier Universitaire Grenobles Alpes, Av. des Maquis du Grésivaudan, 38700 La Tronche, France
| | - Anne Huynh
- Centre Hospitalier Universitaire Toulouse, l’Institut Universitaire du Cancer de Toulouse-Oncopole, 1 Av. Irène Joliot-Curie, 31059 Toulouse, France
| | - Elisabet Viayna
- IQVIA Real World Solutions, Provença 392, 3rd Floor, 08025 Barcelona, Spain
| | - Montserrat Roset
- IQVIA Real World Solutions, Provença 392, 3rd Floor, 08025 Barcelona, Spain
| | - Jonathan Finzi
- Incyte Biosciences France, 35 Ter Avenue André Morizet, 92100 Boulogne-Billancourt, France
| | - Minja Pfeiffer
- Incyte Biosciences International Sàrl, Rue Docteur-Yersin 12, 1110 Morges, Switzerland
| | - Daniel Thunström
- Incyte Biosciences International Sàrl, Rue Docteur-Yersin 12, 1110 Morges, Switzerland
| | - Núria Lara
- IQVIA Real World Solutions, Provença 392, 3rd Floor, 08025 Barcelona, Spain
| | - Lorenzo Sabatelli
- Incyte Biosciences International Sàrl, Rue Docteur-Yersin 12, 1110 Morges, Switzerland
| | - Patrice Chevallier
- Centre Hospitalier Universitaire Nantes, 5 allée de l’Île-Gloriette, 44000 Nantes, France
| | - Maija Itälä-Remes
- Turku University Hospital, Kiinamyllynkatu 4-8, 20521 Turku, Finland
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5
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Seftel MD, Pasic I, Parmar G, Bucher O, Allan DS, Bhella S, Hay KA, Ikuomola O, Musto G, Prica A, Richardson E, Truong TH, Paulson K. Hematopoietic Cell Transplantation Trends and Outcomes in Canada: A Registry-Based Cohort Study. Curr Oncol 2023; 30:9953-9967. [PMID: 37999143 PMCID: PMC10669983 DOI: 10.3390/curroncol30110723] [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: 10/24/2023] [Revised: 11/07/2023] [Accepted: 11/15/2023] [Indexed: 11/25/2023] Open
Abstract
Background: Hematopoietic cell transplantation (HCT) is an established therapy for hematologic malignancies and serious non-malignant blood disorders. Despite its curative potential, HCT is associated with substantial toxicity and health resource utilization. Effective delivery of HCT requires complex hospital-based care, which limits the number of HCT centres in Canada. In Canada, the quantity, indications, temporal trends, and outcomes of patients receiving HCT are not known. Methods: A retrospective cohort study of first transplants reported to the Cell Therapy Transplant Canada (CTTC) registry between 2000 and 2019. We determined overall survival (OS) and non-relapse mortality (NRM), categorizing the cohort into early (2000-2009) and later (2010-2019) eras to investigate temporal changes. Results: Of 18,046 transplants, 7571 were allogeneic and 10,475 were autologous. Comparing the two eras, allogeneic transplants increased in number by 22.3%, with greater use of matched unrelated donors in the later era. Autologous transplants increased by 10.9%. Temporal improvements in NRM were observed in children and adults. OS improved in pediatric patients and in adults receiving autologous HCT. In adults receiving allogeneic HCT, OS was stable despite the substantially older age of patients in the later era. Interpretation: HCT is an increasingly frequent procedure in Canada which has expanded to serve older adults. Noted improvements in NRM and OS reflect progress in patient and donor selection, preparation for transplant, and post-transplant supportive care. In allogeneic HCT, unrelated donors have become the most frequent donor source, highlighting the importance of the continued growth of volunteer donor registries. These results serve as a baseline measure for quality improvement and health services planning in Canada.
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Affiliation(s)
- Matthew D. Seftel
- Canadian Blood Services, Vancouver, BC V6H 2N9, Canada; (G.P.); (D.S.A.)
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada;
| | - Ivan Pasic
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada; (I.P.); (S.B.); (A.P.)
- Faculty of Medicine, University of Toronto, Toronto, ON M5G 2M9, Canada
| | - Gaganvir Parmar
- Canadian Blood Services, Vancouver, BC V6H 2N9, Canada; (G.P.); (D.S.A.)
- Faculty of Medicine, University of Toronto, Toronto, ON M5G 2M9, Canada
| | - Oliver Bucher
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB R3A 1M5, Canada; (O.B.); (O.I.); (G.M.); (E.R.)
| | - David S. Allan
- Canadian Blood Services, Vancouver, BC V6H 2N9, Canada; (G.P.); (D.S.A.)
- Department of Medicine and Biochemistry, Microbiology & Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON K1H 8L6, Canada
| | - Sita Bhella
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada; (I.P.); (S.B.); (A.P.)
- Faculty of Medicine, University of Toronto, Toronto, ON M5G 2M9, Canada
| | - Kevin Anthony Hay
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada;
- Division of Hematology, Department of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Terry Fox Laboratory, British Columbia Cancer Research Institute, Vancouver, BC V5Z 1L3, Canada
| | - Oluwaseun Ikuomola
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB R3A 1M5, Canada; (O.B.); (O.I.); (G.M.); (E.R.)
| | - Grace Musto
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB R3A 1M5, Canada; (O.B.); (O.I.); (G.M.); (E.R.)
| | - Anca Prica
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada; (I.P.); (S.B.); (A.P.)
- Faculty of Medicine, University of Toronto, Toronto, ON M5G 2M9, Canada
| | - Erin Richardson
- Department of Epidemiology, CancerCare Manitoba, Winnipeg, MB R3A 1M5, Canada; (O.B.); (O.I.); (G.M.); (E.R.)
| | - Tony H. Truong
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Calgary, Calgary, AB T3B 6A8, Canada;
| | - Kristjan Paulson
- Cell Therapy and Transplant Canada, Winnipeg, MB R3E 0V9, Canada;
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, MB R3E 0V9, Canada
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6
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Duléry R, Brissot E, Mohty M. Combining post-transplant cyclophosphamide with antithymocyte globulin for graft-versus-host disease prophylaxis in hematological malignancies. Blood Rev 2023; 62:101080. [PMID: 37085459 DOI: 10.1016/j.blre.2023.101080] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 04/23/2023]
Abstract
In search of an ideal partner or alternative to conventional immunosuppressive agents, rabbit anti-thymocyte globulin (ATG) and, more recently, post-transplant cyclophosphamide (PT-Cy) have both emerged as valid and efficient options for preventing graft-versus-host disease (GvHD). To further reduce the risk of GvHD, strategies combining ATG and PT-Cy have recently been investigated. In a haploidentical setting, retrospective studies suggest that combining PT-Cy and ATG may result in a lower incidence of chronic GvHD without increasing the risks of infection or relapse, when compared to PT-Cy without ATG. In haploidentical or unrelated donor settings, adding reduced doses of PT-Cy to ATG may reduce the risk of acute and chronic GvHD and improve survival, particularly GvHD-free, relapse-free survival (GRFS), when compared to ATG without PT-Cy. Overall, the combination of PT-Cy and ATG is a safe and promising approach for patients with hematological malignancies undergoing allogeneic hematopoietic stem cell transplantation (HSCT).
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Affiliation(s)
- Rémy Duléry
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Eolia Brissot
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France
| | - Mohamad Mohty
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; INSERM, UMRs 938, Centre de recherche Saint Antoine (CRSA), Paris, France.
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7
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Varady ES, Ayala LA, Nguyen PU, Scarfone VM, Karimzadeh A, Zhou C, Chen X, Greilach SA, Walsh CM, Inlay MA. Graft conditioning with fluticasone propionate reduces graft-versus-host disease upon allogeneic hematopoietic cell transplantation in mice. EMBO Mol Med 2023; 15:e17748. [PMID: 37538042 PMCID: PMC10493574 DOI: 10.15252/emmm.202317748] [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: 03/23/2023] [Revised: 06/30/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023] Open
Abstract
Hematopoietic cell transplantation (HCT) treats many blood conditions but remains underused due to complications such as graft-versus-host disease (GvHD). In GvHD, donor immune cells attack the patient, requiring powerful immunosuppressive drugs like glucocorticoids (GCs) to prevent death. In this study, we tested the hypothesis that donor cell conditioning with the glucocorticoid fluticasone propionate (FLU) prior to transplantation could increase hematopoietic stem cell (HSC) engraftment and reduce GvHD. Murine HSCs treated with FLU had increased HSC engraftment and reduced severity and incidence of GvHD after transplantation into allogeneic hosts. While most T cells died upon FLU treatment, donor T cells repopulated in the hosts and appeared less inflammatory and alloreactive. Regulatory T cells (Tregs) are immunomodulatory and survived FLU treatment, resulting in an increased ratio of Tregs to conventional T cells. Our results implicate an important role for Tregs in maintaining allogeneic tolerance in FLU-treated grafts and suggest a therapeutic strategy of pre-treating donor cells (and not the patients directly) with GCs to simultaneously enhance engraftment and reduce GvHD upon allogeneic HCT.
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Affiliation(s)
- Erika S Varady
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
| | - L Angel Ayala
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
| | - Pauline U Nguyen
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
| | - Vanessa M Scarfone
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
| | - Alborz Karimzadeh
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
- Present address:
Joslin Diabetes CenterHarvard Medical SchoolBostonMAUSA
| | - Cuiwen Zhou
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
| | - Xiyu Chen
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
| | - Scott A Greilach
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
| | - Craig M Walsh
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
| | - Matthew A Inlay
- Sue and Bill Gross Stem Cell Research CenterUniversity of California IrvineIrvineCAUSA
- Department of Molecular Biology and BiochemistryUniversity of California IrvineIrvineCAUSA
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8
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Tang L, Huang Z, Mei H, Hu Y. Immunotherapy in hematologic malignancies: achievements, challenges and future prospects. Signal Transduct Target Ther 2023; 8:306. [PMID: 37591844 PMCID: PMC10435569 DOI: 10.1038/s41392-023-01521-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 08/19/2023] Open
Abstract
The immune-cell origin of hematologic malignancies provides a unique avenue for the understanding of both the mechanisms of immune responsiveness and immune escape, which has accelerated the progress of immunotherapy. Several categories of immunotherapies have been developed and are being further evaluated in clinical trials for the treatment of blood cancers, including stem cell transplantation, immune checkpoint inhibitors, antigen-targeted antibodies, antibody-drug conjugates, tumor vaccines, and adoptive cell therapies. These immunotherapies have shown the potential to induce long-term remission in refractory or relapsed patients and have led to a paradigm shift in cancer treatment with great clinical success. Different immunotherapeutic approaches have their advantages but also shortcomings that need to be addressed. To provide clinicians with timely information on these revolutionary therapeutic approaches, the comprehensive review provides historical perspectives on the applications and clinical considerations of the immunotherapy. Here, we first outline the recent advances that have been made in the understanding of the various categories of immunotherapies in the treatment of hematologic malignancies. We further discuss the specific mechanisms of action, summarize the clinical trials and outcomes of immunotherapies in hematologic malignancies, as well as the adverse effects and toxicity management and then provide novel insights into challenges and future directions.
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Affiliation(s)
- Lu Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China
| | - Zhongpei Huang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China
| | - Heng Mei
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China.
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China.
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
- Hubei Clinical Medical Center of Cell Therapy for Neoplastic Disease, 430022, Wuhan, China.
- Key Laboratory of Biological Targeted Therapy, the Ministry of Education, 430022, Wuhan, China.
- Hubei Key Laboratory of Biological Targeted Therapy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022, Wuhan, China.
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9
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Farhan S, Holtan SG. Graft-versus-host disease: teaching old drugs new tricks at less cost. Front Immunol 2023; 14:1225748. [PMID: 37600820 PMCID: PMC10435076 DOI: 10.3389/fimmu.2023.1225748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Graft-versus-host disease (GVHD) remains a major cause of morbidity and mortality after allogeneic stem cell transplantation (SCT). Currently, more patients can receive SCT. This is attributed to the use of reduced intensity regimens and the use of different GVHD prophylaxis that breaks the barrier of human leukocyte antigen, allowing an increase in the donor pool. Once an area with relatively few clinical trial options, there has been an increase in interest in GVHD prophylaxis and treatment, which has led to many US Food and Drug Administration (FDA) approvals. Although there is considerable excitement over novel therapies, many patients may not have access to them due to geographical or other resource constraints. In this review article, we summarize the latest evidence on how we can continue to repurpose drugs for GVHD prophylaxis and treatment. Drugs covered by our review include those that have been FDA approved for other uses for at least 15 years (since 2008); thus, they are likely to have generic equivalents available now or in the near future.
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Affiliation(s)
- Shatha Farhan
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, United States
| | - Shernan G. Holtan
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, United States
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10
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Malard F, Loschi M, Huynh A, Cluzeau T, Guenounou S, Legrand F, Magro L, Orvain C, Charbonnier A, Panz-Klapuch M, Desmier D, Mear JB, Cornillon J, Robin C, Daguindau E, Bilger K, Vehreschild MJ, Chevallier P, Labussière-Wallet H, Mediavilla C, Couturier MA, Bulabois CE, Camus V, Chantepie S, Ceballos P, Gaugler B, Holler E, Doré J, Prestat E, Gasc C, Plantamura E, Mohty M. Pooled allogeneic faecal microbiota MaaT013 for steroid-resistant gastrointestinal acute graft-versus-host disease: a single-arm, multicentre phase 2 trial. EClinicalMedicine 2023; 62:102111. [PMID: 37654670 PMCID: PMC10466244 DOI: 10.1016/j.eclinm.2023.102111] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 09/02/2023] Open
Abstract
Background Failure of gastrointestinal acute graft-versus-host disease (GI-aGvHD) to respond to steroid therapy is associated with limited further therapeutic options. We aimed to assess the safety and efficacy of the first-in-human use of the pooled allogeneic faecal microbiota, MaaT013, for the treatment of steroid-refractory GI-aGvHD. Methods This prospective, international, single-arm, phase 2a study reports clinical outcomes from a 24-patient cohort with grade III-IV, steroid refractory GI-aGvHD treated with the pooled allogeneic faecal microbiota MaaT013. MaaT013 involved pooling faecal matter from 3 to 8 screened donors then transplanting the pooled batches into patients to treat GI-aGVHD. The 24 patients were treated in the HERACLES study (Aug 2018 to Nov 2020) at 26 sites in Europe and an additional 52 patients were treated in a compassionate use/expanded access program (EAP) in France (July 2018 to April 2021). The primary endpoint was GI response at day 28, defined as the proportion of patients with GI-aGvHD who had a complete response (CR) or very good partial response (VGPR). GvHD grading and staging were assessed according to the revised Glucksberg criteria. Adverse events and severe adverse events were monitored for 6 months and 12 months, respectively. The HERACLES study was registered with ClinicalTrials.gov (NCT03359980). Findings Compared with single donors, MaaT013 is characterised by higher microbial richness and reduced variability across batches. At day 28 (D28), the GI-overall response rate (ORR) was 38% in the prospective population, including 5 complete responses (CR), 2 very good partial responses (VGPR) and 2 partial responses (PR). In the EAP, the GI-ORR was 58% (17 CR, 9 VGPR and 4 PR). The 12-month overall survival (OS) was 25% in the prospective study and 38% in the EAP. Regarding safety, five infectious complications, including 3 sepsis, could not be excluded from being related to the study procedure in HERACLES. Shotgun sequencing analyses of the identified strains suggest that none were found in MaaT013. In the EAP, 18 pharmacovigilance cases were reported among 52 treated patients, including 11 bacteraemia/sepsis. In HERACLES, we observed in stools from responding patients at D28 a higher microbiota richness and increased levels of beneficial bacteria, in particular butyrate producers, along with increased levels of short-chain fatty acid and bile acids. In contrast, stools from non-responding (NR) patients displayed increased levels of pathogenic pro-inflammatory bacteria along with increased systemic inflammatory parameters. Interpretation Overall, MaaT013 was safe in this population of highly immunocompromised patients and was associated with responses in some patients with GI-aGvHD and deserves further investigation. Funding MaaT Pharma.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, AP-HP, Centre de Recherche Saint-Antoine INSERM UMRs938, Service D'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Michael Loschi
- Haematology Department, CHU of Nice, Cote D'Azur University, France
| | - Anne Huynh
- Service Hématologie, CHU/IUCT-Oncopole, Toulouse Cédex 31059, France
| | - Thomas Cluzeau
- Haematology Department, CHU of Nice, Cote D'Azur University, France
| | - Sarah Guenounou
- Service Hématologie, CHU/IUCT-Oncopole, Toulouse Cédex 31059, France
| | - Faezeh Legrand
- Haematology Department, Institut Paoli Calmettes, Marseille, France
| | - Leonardo Magro
- Unité d'Allogreffe, Maladies du sang, CHRU, Lille 59000, France
| | | | | | - Marta Panz-Klapuch
- Department of Haematology and Bone Marrow Transplantation, School of Medicine in Katowice, Medical University of Silesia, Dąbrowski Street, 25, Katowice 40-032, Poland
| | - Deborah Desmier
- CHU de Poitiers, Service d’Hématologie et de Thérapie Cellulaire, Poitiers, France
| | | | - Jérôme Cornillon
- Département d’Hématologie Clinique et de Thérapie Cellulaire, CHU de St-Etienne, Saint-Etienne, France
| | - Christine Robin
- Hôpital Henri Mondor, Service d’Hématologie Clinique et de Thérapie Cellulaire, Créteil, France
| | | | - Karin Bilger
- Hôpital de Hautepierre, Pôle Oncologie-Hématologie, Strasbourg, France
| | | | | | | | | | | | | | - Vincent Camus
- Department of Haematology and INSERM U1245, Centre Henri Becquerel, Rouen, France
| | - Sylvain Chantepie
- Institut d’Hématologie de Basse Normandie, CHU Caen Normandie, Caen, France
| | | | - Béatrice Gaugler
- Sorbonne Université, AP-HP, Centre de Recherche Saint-Antoine INSERM UMRs938, Service D'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Ernst Holler
- Department of Internal Medicine III, University Medical Centre, Regensburg, Germany
| | - Joël Doré
- INRAE, MGP, Université Paris-Saclay, Jouy-en-Josas 78350, France
| | | | | | | | - Mohamad Mohty
- Sorbonne Université, AP-HP, Centre de Recherche Saint-Antoine INSERM UMRs938, Service D'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
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11
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Maximova N, Nisticò D, Riccio G, Maestro A, Barbi E, Faganel Kotnik B, Marcuzzi A, Rimondi E, Di Paolo A. Advantage of First-Line Therapeutic Drug Monitoring-Driven Use of Infliximab for Treating Acute Intestinal and Liver GVHD in Children: A Prospective, Single-Center Study. Cancers (Basel) 2023; 15:3605. [PMID: 37509268 PMCID: PMC10376946 DOI: 10.3390/cancers15143605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
The high serum concentrations of TNF-α characterize acute graft-versus-host disease (aGVHD), for which infliximab treatment may be beneficial. In 28 pediatric patients, four doses of 10 mg/kg infliximab every seven days were administered after steroid failure (Standard Group, n = 14) or as a first-line therapy (Early Group, n = 14). Population pharmacokinetic analyses and evaluation of serum cytokines were performed. After two months of treatment, complete response in gastrointestinal and liver aGVHD was achieved in 43% and 100% of patients in the Standard and Early groups, respectively. During follow-up, four patients in the Standard Group (but none in the Early Group) experienced an aGVHD recurrence. Viral infections occurred more frequently in the Standard Group after the fifth dose. Infliximab clearance did not differ between groups or according to treatment outcome for each organ involved in aGVHD, whereas serum levels of cytokines significantly differed. Therefore, present findings show that use of first-line, TDM-driven infliximab to treat aGVHD in children may result in better clinical outcomes and tolerability, with a different pattern of cytokines generated according to the moment of beginning of treatment.
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Affiliation(s)
- Natalia Maximova
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Daniela Nisticò
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Guglielmo Riccio
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Alessandra Maestro
- Pharmacy and Clinical Pharmacology Unit, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Egidio Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, 34137 Trieste, Italy
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Barbara Faganel Kotnik
- Department of Hematology and Oncology, University Children's Hospital, 1000 Ljubljana, Slovenia
| | - Annalisa Marcuzzi
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Erika Rimondi
- Department of Translational Medicine and LTTA Centre, University of Ferrara, 44121 Ferrara, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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12
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Malard F, Holler E, Sandmaier BM, Huang H, Mohty M. Acute graft-versus-host disease. Nat Rev Dis Primers 2023; 9:27. [PMID: 37291149 DOI: 10.1038/s41572-023-00438-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/10/2023]
Abstract
Acute graft-versus-host disease (GVHD) is a common immune complication that can occur after allogeneic haematopoietic cell transplantation (alloHCT). Acute GVHD is a major health problem in these patients, and is associated with high morbidity and mortality. Acute GVHD is caused by the recognition and the destruction of the recipient tissues and organs by the donor immune effector cells. This condition usually occurs within the first 3 months after alloHCT, but later onset is possible. Targeted organs include the skin, the lower and upper gastrointestinal tract and the liver. Diagnosis is mainly based on clinical examination, and complementary examinations are performed to exclude differential diagnoses. Preventive treatment for acute GVHD is administered to all patients who receive alloHCT, although it is not always effective. Steroids are used for first-line treatment, and the Janus kinase 2 (JAK2) inhibitor ruxolitinib is second-line treatment. No validated treatments are available for acute GVHD that is refractory to steroids and ruxolitinib, and therefore it remains an unmet medical need.
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Affiliation(s)
- Florent Malard
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
| | - Ernst Holler
- University Hospital of Regensburg, Department of Internal Medicine 3, Regensburg, Germany
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Center, Translational Science and Therapeutics Division, Seattle, WA, USA
- University of Washington School of Medicine, Division of Medical Oncology, Seattle, WA, USA
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, Hangzhou, China
- Engineering Laboratory for Stem Cell and Immunity Therapy, Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Mohamad Mohty
- Sorbonne Université, Centre de Recherche Saint-Antoine INSERM UMRs938, Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France.
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13
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Patel DA, Crain M, Pusic I, Schroeder MA. Acute Graft-versus-Host Disease: An Update on New Treatment Options. Drugs 2023:10.1007/s40265-023-01889-2. [PMID: 37247105 DOI: 10.1007/s40265-023-01889-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/30/2023]
Abstract
Acute graft-versus-host disease (GVHD) occurs in approximately 50% of patients and remains a primary driver of non-relapse and transplant-related mortality. The best treatment remains prevention with either in vivo or ex vivo T-cell depletion, with multiple strategies used worldwide based on factors such as institution preference, ability to perform graft manipulation, and ongoing clinical trials. Predicting patients at high risk for developing severe acute GVHD based on clinical and biomarker-based criteria allows for escalation or potential de-escalation of therapy. Modern therapies for treatment of the disease include JAK/STAT pathway inhibitors, which are standard of care in the second-line setting and are being investigated for upfront management of non-severe risk based on biomarkers. Salvage therapies beyond the second-line remain suboptimal. In this review, we will focus on the most clinically used GVHD prevention and treatment strategies, including the accumulating data on JAK inhibitors in both settings.
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Affiliation(s)
- Dilan A Patel
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Mallory Crain
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Iskra Pusic
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA
| | - Mark A Schroeder
- Section of BMT & Leukemia, Division of Oncology, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, MO, USA.
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14
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Squillaci D, Marcuzzi A, Rimondi E, Riccio G, Barbi E, Zanon D, Maximova N. Defibrotide impact on the acute GVHD disease incidence in pediatric hematopoietic stem cell transplant recipients. Life Sci Alliance 2023; 6:e202201786. [PMID: 36878639 PMCID: PMC9990457 DOI: 10.26508/lsa.202201786] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
Despite advances in acute graft-versus-host disease (aGVHD) prophylaxis, current pharmacological approaches fail to prevent aGVHD. The protective effect of defibrotide on GVHD incidence and GVHD-free survival has not been sufficiently studied. 91 pediatric patients included in this retrospective study were divided into two groups based on defibrotide use. We compared the incidence of aGVHD and chronic GVHD-free survival between the defibrotide and control groups. The incidence and severity of aGVHD were significantly lower in patients who received defibrotide prophylactic administration than in the control group. This improvement was observed in the liver and intestinal aGVHD. No defibrotide prophylaxis benefit was observed in the prevention of chronic GVHD. The pro-inflammatory cytokine levels were significantly higher in the control group. Our findings suggest that prophylactic administration of defibrotide in pediatric patients significantly reduces the incidence and severity of aGVHD, with a modification of cytokine pattern, both strongly coherent with the protective drug's action. This evidence adds to pediatric retrospective studies and preclinical data suggesting a possible defibrotide role in this setting.
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Affiliation(s)
- Domenica Squillaci
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Annalisa Marcuzzi
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Erika Rimondi
- Department of Translational Medicine and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Guglielmo Riccio
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Egidio Barbi
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Davide Zanon
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Natalia Maximova
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
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15
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Maruyama Y, Maejima Y, Hirabayashi K, Morokawa H, Okura E, Saito S, Nakazawa Y. Factors Affecting Day-to-Day Variations in Tacrolimus Concentration among Children and Young Adults Undergoing Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:270.e1-270.e8. [PMID: 36682473 DOI: 10.1016/j.jtct.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/16/2022] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
Tacrolimus is widely used as prophylaxis for graft-versus-host disease (GVHD) in allogeneic stem cell transplantation (allo-HSCT). It has a narrow therapeutic index range; high tacrolimus concentrations are associated with toxicity, whereas low concentrations are associated with an increased risk of GVHD. Although dose adjustments based on therapeutic drug monitoring are performed, unexpected large variations in tacrolimus concentration are sometimes encountered. The available evidence suggests that the factors affecting tacrolimus concentration are not fully understood. This study was aimed primarily at investigating the factors affecting day-to-day variations in tacrolimus concentration in children and young adults who received continuous tacrolimus infusion after allo-HSCT. The secondary objective was to identify the factors causing large variations (>20%) in tacrolimus concentrations. This retrospective cohort study comprised 123 consecutive pediatric and young adult patients (age <25 years) who received continuous i.v. tacrolimus infusion after allo-HSCT at Shinshu University Hospital, Matsumoto, Japan, between January 2009 and December 2021. To compare day-to-day variations in tacrolimus concentration without consideration of the tacrolimus dose, 2 consecutive days when the tacrolimus dose was not changed were selected from between the first post-allo-HSCT day of a tacrolimus concentration >7 ng/mL and day 28 post-allo-HSCT. Subsequently, information for the subsequent 24 hours was collected along with the tacrolimus concentrations and hematocrit values. Tacrolimus concentration was determined using whole blood samples. Tacrolimus concentrations were significantly higher in patients who received red blood cell concentrate (RCC) transfusions (P < .0001) and methotrexate (P = .0162), patients with persistent fever (P = .0056), and patients with a decline in fever (P = .0003). In contrast, tacrolimus concentrations were significantly lower in patients who received platelet concentrate (PC) transfusions (P < .0001), who redeveloped fever (P = .0261), and who had a replaced tacrolimus administration route set (P = .0008). Variations in tacrolimus concentration were significantly correlated with variations in hematocrit (r = .556; P < .0001). Body weight (P < .0001), RCC transfusion (P < .0001), methotrexate use (P = .0333), persistent fever (P = .0150), and decline in fever (P = .0073) were associated with a sharp increase in tacrolimus concentration. In contrast, body weight (P < .0001), PC transfusion (P = .0025), and replacement of the tacrolimus administration route set (P = .0025) were associated with a sharp decrease in tacrolimus concentration. RCC and PC transfusions, fever, methotrexate administration, and replacement of the tacrolimus administration route set were independent factors affecting day-to-day variations in tacrolimus concentration. In addition to these factors, low body weight was a risk factor for both sharp increases and decreases in tacrolimus concentration. These findings suggest the need for better control of tacrolimus concentration using whole blood samples.
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Affiliation(s)
- Yuta Maruyama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuya Maejima
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koichi Hirabayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Hirokazu Morokawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Eri Okura
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shoji Saito
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yozo Nakazawa
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
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16
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Mohty M, Malard F. IL-22, a new beacon in gastrointestinal aGVHD. Blood 2023; 141:1369-1370. [PMID: 36951884 DOI: 10.1182/blood.2022018934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
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17
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Solh MM, Farnham C, Solomon SR, Bashey A, Morris LE, Holland HK, Zhang X. Extracorporeal photopheresis (ECP) improves overall survival in the treatment of steroid refractory acute graft-versus-host disease (SR aGvHD). Bone Marrow Transplant 2023; 58:168-174. [PMID: 36352015 DOI: 10.1038/s41409-022-01860-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
Steroid refractory acute graft-versus-host disease (SR aGvHD) is a major limitation of successful allogeneic hematopoietic stem cell transplantation (HSCT). Extracorporeal photopheresis (ECP) has been used to treat SR aGvHD effectively and with low treatment related toxicity. In this study, we retrospectively analyzed the outcomes of 103 Steroid Refractory aGvHD (SR aGvHD) patients to identify factors associated with improved outcomes including the use of ECP. A total of 79 patients received ECP as part of their SR aGVHD treatment compared to 24 patients who did not. Both groups had similar aGVHD grade and maximum organ stage at onset of aGVHD and treatment initiation. Patients in the group that received ECP had better OS (p = 0.01), DFS (p = 0.008), lower relapse (p = 0.05) and similar NRM compared to the group that did not receive ECP. Patients that received ECP treatment also had shorter hospital stays in the first 180 days after onset of SR aGvHD (20 vs. 38 days, p = 0.03). Multivariable analysis for OS indicated patient CMV status (CMV+ versus CMV-, HR 2.34, CI 1.16-4.69), regimen intensity (Myelo vs. non-Myeloablative, HR 0.39, CI 0.20-0.75), and the use of ECP (ECP vs. no ECP, HR 0.39, CI 0.20-0.75) were associated with OS. In summary, the use of ECP in the treatment of SR aGvHD results in improved overall survival secondary to lower relapse rates compared to other therapeutic modalities that do not incorporate ECP.
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Affiliation(s)
- Melhem M Solh
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA.
| | - Chloe Farnham
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Scott R Solomon
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Asad Bashey
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Lawrence E Morris
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - H Kent Holland
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Xu Zhang
- Center for Clinical and Translational Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA
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18
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Raman HS, Kim SE, DeAngelo DJ, Stevenson KE, Neuberg D, Winer ES, Wadleigh M, Garcia JS, Kim AS, Stone RM, Ho VT, Luskin MR. Intensity of induction regimen and outcomes among adults with Ph+ALL undergoing allogeneic hematopoietic stem cell transplantation. Leuk Res 2023; 125:107004. [PMID: 36577290 DOI: 10.1016/j.leukres.2022.107004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
Tyrosine kinase inhibitors (TKIs) are essential for the treatment of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) and have allowed for effective, low intensity induction regimens including no or minimal chemotherapy. Whether the use of low intensity induction regimens impacts outcomes after allogeneic hematopoietic stem cell transplant (alloHCT) is less understood. We identified consecutive adult patients with Ph+ ALL undergoing alloHCT in first complete remission (CR1) at our center from 2010 to 2021 and examined the impact of pre-transplant induction intensity on outcomes. Among the 87 identified patients, 44 (51%) received low intensity induction and 43 (49%) received induction with high intensity chemotherapy. Patients receiving low intensity induction were older (median age 60 vs. 47 years, p < 0.01). Following induction, measurable residual disease (MRD) negativity by BCR::ABL1 RT-PCR was similar in the low and high intensity induction cohorts (54% and 52% respectively). Receipt of reduced intensity transplant conditioning was not associated with intensity of induction regimen (39% vs. 19% in low vs. high, respectively, p = 0.06). At a median follow-up of 21 months from transplant, there was no difference between low and high intensity induction with respect to 2-year disease-free survival (58% vs. 56%), 2-year overall survival (62% vs. 63%), 2-year cumulative incidence of relapse (9% vs. 17%), and 2-year non-relapse mortality (33% vs. 29%). We also found no difference in outcomes when patients were segmented by both induction and conditioning regimen intensities. Our retrospective analysis suggests that induction intensity does not impact post-transplant outcomes among patients with Ph+ ALL transplanted in CR1.
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Affiliation(s)
- Hari S Raman
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Se Eun Kim
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | | | - Donna Neuberg
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Eric S Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Jacqueline S Garcia
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Annette S Kim
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA.
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Vincent T Ho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Marlise R Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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19
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Chen X, Xun Z, Yuska B, McGee R, Yeleswaram S. Itacitinib Population Pharmacokinetics and Exposure-Response in Patients With Acute Graft-Versus-Host Disease. J Clin Pharmacol 2023; 63:622-632. [PMID: 36601737 DOI: 10.1002/jcph.2202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023]
Abstract
This article presents the population pharmacokinetic (PopPK) analysis and exposure-response analyses for the primary efficacy end point-acute graft-versus-host disease (aGVHD) day 28 response-and select safety measures (incidence of thrombocytopenia, hypertriglyceridemia, and cytomegalovirus infection) from a phase 3 randomized, double-blind study comparing itacitinib plus corticosteroids versus placebo plus corticosteroids for the treatment of aGVHD. The PopPK data set contained sparse data from patients with aGVHD and select enriched data from healthy volunteers. The structural model was a 2-compartment model with first-order elimination and dose-dependent nonlinear absorption with dual first-order absorption pathways with lag times. Strong cytochrome P450 (CYP) 3A inhibitor coadministration, moderate renal impairment, and participant population (healthy volunteers vs patients with aGVHD) were covariates on apparent clearance. Participant population was also a covariate on apparent intercompartmental clearance and lag time of the secondary absorption compartment. Apparent clearance decreased 42% with coadministration of strong CYP3A inhibitors. Simulations supported the following dose reductions with concomitant use of a strong CYP3A inhibitor: 300 mg once daily to 200 mg once daily, 400 mg once daily to 300 mg once daily, and 600 mg once daily to 400 mg once daily. No dose adjustment is recommended for any other covariate based on the magnitude of impact when they were retained in the model. The exposure-response relationship was characterized between itacitinib exposure and probability of aGVHD day 28 response using a linear logistic regression model. Both itacitinib exposure and aGVHD risk status were significant predictors of response. There was no relationship between itacitinib exposure and thrombocytopenia, hypertriglyceridemia, or cytomegalovirus infection.
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20
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Holtan SG, Yu J, Choe HK, Paranagama D, Tang J, Naim A, Galvin J, Joachim Deeg H. Disease progression, treatments, hospitalization, and clinical outcomes in acute GVHD: a multicenter chart review. Bone Marrow Transplant 2022; 57:1581-1585. [PMID: 35908108 PMCID: PMC9576589 DOI: 10.1038/s41409-022-01764-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/24/2022]
Abstract
Acute graft-versus-host disease (GVHD) remains a barrier to successful allogeneic hematopoietic cell transplantation (HCT) outcomes. This multicenter, retrospective chart review describes disease progression, treatment patterns, hospitalizations, and clinical outcomes among 475 patients (≥12 years old) who developed grades II–IV acute GVHD after their first HCT (January 2014–June 2016). Median (interquartile range) age at HCT was 55 (44–63) years. From the date of acute GVHD diagnosis, 190 patients (40.0%) experienced progression to more severe disease and/or developed new organ involvement. Among 431 patients with grades II–IV acute GVHD at diagnosis, 73.1% received first-line systemic corticosteroids. During follow-up (median 524 days since acute GVHD diagnosis), 23.4% of patients had an increase in steroid dose and 44.4% were unable to taper below 10 mg/day. Over half of patients (54.9%) required ≥1 hospital readmission within 100 days post-HCT (≥2 readmissions in 22.3%); mean inpatient length of stay upon readmission was 27.5 days. Approximately half of patients (52.8%) died during follow-up; 1-year overall mortality from date of acute GVHD diagnosis and nonrelapse mortality rates were 35.2% and 25.5%, respectively. Overall, patients who developed acute GVHD following HCT had poor clinical outcomes, highlighting the unmet need for early and effective treatment strategies.
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Affiliation(s)
| | - Jingbo Yu
- Incyte Corporation, Wilmington, DE, USA
| | | | | | | | | | - John Galvin
- Incyte Corporation, Wilmington, DE, USA.,University of Illinois Cancer Center, Chicago, IL, USA
| | - H Joachim Deeg
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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21
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Kwan ACF, Blosser N, Ghosh S, Leyshon C, Dersch-Mills D, Puckrin RP, Duggan P, Zepeda V, Savoie L, Stewart D, Storek J, Jamani K. Toward optimization of cyclosporine concentration target to prevent acute graft-vs-host disease following myeloablative allogeneic stem cell transplant. Clin Transplant 2022; 36:e14732. [PMID: 35606904 DOI: 10.1111/ctr.14732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/09/2022] [Accepted: 05/14/2022] [Indexed: 11/28/2022]
Abstract
Despite the common use of cyclosporine (CsA) for acute graft-versus-host disease (aGVHD) prophylaxis following allogeneic stem cell transplant, the optimal CsA trough target remains unknown. Here, we report on outcomes of adult patients following myeloablative conditioning to identify an optimal CsA trough target and characterize the most relevant timeframe post-transplant for CsA trough targeting to minimize aGVHD. We retrospectively reviewed 399 consecutive patients who underwent first peripheral blood allogeneic stem cell transplant for hematological malignancies between January 2009 and December 2018. In the unadjusted and adjusted analyses, the incidence of grades 2-4 aGVHD was significantly higher among patients with an average CsA trough concentration <250 mcg/L compared to patients with an average CsA trough concentration ≥250 mcg/L during days 15-28 post-transplant (31.5% versus 18.8%, P = 0.037), with an odds ratio (OR) of 1.97 (95% confidence interval 1.04-3.71). In contrast, no correlations between CsA trough concentration and relapse, non-relapse mortality and overall survival was found. In conclusion, early post-transplant CsA trough concentrations are an important factor in the prophylaxis against aGVHD. Our findings suggest that CsA trough concentrations should be maximized between days 15-28 post-myeloablative transplant. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Nikki Blosser
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | | | | | | | - Peter Duggan
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Victor Zepeda
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Lynn Savoie
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Douglas Stewart
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Jan Storek
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
| | - Kareem Jamani
- Alberta Blood & Marrow Transplant Program, Calgary, Alberta, Canada
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22
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Biliński J, Jasiński M, Basak GW. The Role of Fecal Microbiota Transplantation in the Treatment of Acute Graft-versus-Host Disease. Biomedicines 2022; 10:biomedicines10040837. [PMID: 35453587 PMCID: PMC9027325 DOI: 10.3390/biomedicines10040837] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 12/11/2022] Open
Abstract
The number of allogeneic hematopoietic stem cell transplantations conducted worldwide is constantly rising. Together with that, the absolute number of complications after the procedure is increasing, with graft-versus-host disease (GvHD) being one of the most common. The standard treatment is steroid administration, but only 40–60% of patients will respond to the therapy and some others will be steroid-dependent. There is still no consensus regarding the best second-line option, but fecal microbiota transplantation (FMT) has shown encouraging preliminary and first clinically relevant results in recent years and seems to offer great hope for patients. The reason for treatment of steroid-resistant acute GvHD using this method derives from studies showing the significant immunomodulatory role played by the intestinal microbiota in the pathogenesis of GvHD. Depletion of commensal microbes is accountable for aggravation of the disease and is associated with decreased overall survival. In this review, we present the pathogenesis of GvHD, with special focus on the special role of the gut microbiota and its crosstalk with immune cells. Moreover, we show the results of studies and case reports to date regarding the use of FMT in the treatment of steroid-resistant acute GvHD.
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Affiliation(s)
- Jarosław Biliński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Human Biome Institute, 80-137 Gdansk, Poland
- Correspondence:
| | - Marcin Jasiński
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Doctoral School, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Grzegorz W. Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.J.); (G.W.B.)
- Human Biome Institute, 80-137 Gdansk, Poland
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23
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Liu X, Cao Y, Guo Y, Gong X, Feng Y, Wang Y, Wang M, Cui M, Guo W, Zhang L, Zhao N, Song X, Zheng X, Chen X, Shen Q, Zhang S, Song Z, Li L, Feng S, Han M, Zhu X, Jiang E, Chen J. Dynamic forecasting of severe acute graft-versus-host disease after transplantation. NATURE COMPUTATIONAL SCIENCE 2022; 2:153-159. [PMID: 38177449 PMCID: PMC10766514 DOI: 10.1038/s43588-022-00213-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/14/2022] [Indexed: 01/06/2024]
Abstract
Forecasting of severe acute graft-versus-host disease (aGVHD) after transplantation is a challenging 'large p, small n' problem that suffers from nonuniform data sampling. We propose a dynamic probabilistic algorithm, daGOAT, that accommodates sampling heterogeneity, integrates multidimensional clinical data and continuously updates the daily risk score for severe aGVHD onset within a two-week moving window. In the studied cohorts, the cross-validated area under the receiver operator characteristic curve (AUROC) of daGOAT rose steadily after transplantation and peaked at ≥0.78 in both the adult and pediatric cohorts, outperforming the two-biomarker MAGIC score, three-biomarker Ann Arbor score, peri-transplantation features-based models and XGBoost. Simulation experiments indicated that the daGOAT algorithm is well suited for short time-series scenarios where the underlying process for event generation is smooth, multidimensional and where there are frequent and irregular data missing. daGOAT's broader utility was demonstrated by performance testing on a remotely different task, that is, prediction of imminent human postural change based on smartphone inertial sensor time-series data.
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Affiliation(s)
- Xueou Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yigeng Cao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Ye Guo
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xiaowen Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yahui Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yao Wang
- Yidu Cloud Technology Inc., Beijing, China
| | - Mingyang Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | | | - Wenwen Guo
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Luyang Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Ningning Zhao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xiaoqiang Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xuetong Zheng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xia Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Qiujin Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Song Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Zhen Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Linfeng Li
- Yidu Cloud Technology Inc., Beijing, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
| | - Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
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24
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Makris S, de Winde CM, Horsnell HL, Cantoral-Rebordinos JA, Finlay RE, Acton SE. Immune function and dysfunction are determined by lymphoid tissue efficacy. Dis Model Mech 2022; 15:dmm049256. [PMID: 35072206 PMCID: PMC8807573 DOI: 10.1242/dmm.049256] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Lymphoid tissue returns to a steady state once each immune response is resolved, and although this occurs multiple times throughout life, its structural integrity and functionality remain unaffected. Stromal cells orchestrate cellular interactions within lymphoid tissue, and any changes to the microenvironment can have detrimental outcomes and drive disease. A breakdown in lymphoid tissue homeostasis can lead to a loss of tissue structure and function that can cause aberrant immune responses. This Review highlights recent advances in our understanding of lymphoid tissue function and remodelling in adaptive immunity and in disease states. We discuss the functional role of lymphoid tissue in disease progression and explore the changes to lymphoid tissue structure and function driven by infection, chronic inflammatory conditions and cancer. Understanding the role of lymphoid tissues in immune responses to a wide range of pathologies allows us to take a fuller systemic view of disease progression.
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Affiliation(s)
- Spyridon Makris
- Stromal Immunology Group, MRC Laboratory for Molecular Cell Biology, University College London, Gower Street, London WC1E 6BT, UK
| | - Charlotte M. de Winde
- Department for Molecular Cell Biology and Immunology, Amsterdam UMC, location VUmc, De Boelelaan 1108, 1081 HZ Amsterdam, Netherlands
| | - Harry L. Horsnell
- Stromal Immunology Group, MRC Laboratory for Molecular Cell Biology, University College London, Gower Street, London WC1E 6BT, UK
| | - Jesús A. Cantoral-Rebordinos
- Stromal Immunology Group, MRC Laboratory for Molecular Cell Biology, University College London, Gower Street, London WC1E 6BT, UK
| | - Rachel E. Finlay
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester M13 9PL, UK
| | - Sophie E. Acton
- Stromal Immunology Group, MRC Laboratory for Molecular Cell Biology, University College London, Gower Street, London WC1E 6BT, UK
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25
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Zeiser R, Socié G, Schroeder MA, Abhyankar S, Vaz CP, Kwon M, Clausen J, Volodin L, Giebel S, Chacon MJ, Meyers G, Ghosh M, Deeren D, Sanz J, Morariu-Zamfir R, Arbushites M, Lakshminarayanan M, Barbour AM, Chen YB. Efficacy and safety of itacitinib versus placebo in combination with corticosteroids for initial treatment of acute graft-versus-host disease (GRAVITAS-301): a randomised, multicentre, double-blind, phase 3 trial. Lancet Haematol 2022; 9:e14-e25. [DOI: 10.1016/s2352-3026(21)00367-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 12/21/2022]
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26
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Newell LF, Holtan SG. Acute GVHD: think before you treat. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:642-647. [PMID: 34889409 PMCID: PMC8791180 DOI: 10.1182/hematology.2021000300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The treatment of acute graft-versus-host disease (aGVHD) has become more nuanced in recent years with the development of improved risk classification systems and a better understanding of its complex, multisystem pathophysiology. We review contemporary approaches to the risk stratification and initial treatment of aGVHD, including ongoing clinical trials. We summarize the findings that led to the first US Food and Drug Administration approval for steroid-refractory aGVHD (SR-aGVHD), ruxolitinib, as well as some of the challenges clinicians still face in treating SR-aGVHD. Finally, we discuss the evaluation and management of steroid-dependent aGVHD, which affects approximately one-third of patients who have long-term, waxing and waning symptoms distinct from chronic GVHD. Future clinical trials for aGVHD treatment may identify steroid-sparing approaches for patients who have a high likelihood of response and approaches to improve tissue repair and dysbiosis for those unlikely to respond to immunosuppression alone.
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Affiliation(s)
- Laura F Newell
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health and Science University, Portland, OR
| | - Shernan G Holtan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
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27
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Judickas Š, Stasiūnaitis R, Žučenka A, Žvirblis T, Šerpytis M, Šipylaitė J. Outcomes and Risk Factors of Critically Ill Patients with Hematological Malignancy. Prospective Single-Centre Observational Study. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121317. [PMID: 34946262 PMCID: PMC8707137 DOI: 10.3390/medicina57121317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/27/2021] [Accepted: 11/29/2021] [Indexed: 01/06/2023]
Abstract
Background and Objectives: Oncohematological patients have a high risk of mortality when they need treatment in an intensive care unit (ICU). The aim of our study is to analyze the outcomes of oncohemathological patients admitted to the ICU and their risk factors. Materials and Methods: A prospective single-center observational study was performed with 114 patients from July 2017 to December 2019. Inclusion criteria were transfer to an ICU, hematological malignancy, age >18 years, a central line or arterial line inserted or planned to be inserted, and a signed informed consent form. Univariate and multivariable logistic regression models were used to evaluate the potential risk factors for ICU mortality. Results: ICU mortality was 44.74%. Invasive mechanical ventilation in ICU was used for 55.26% of the patients, and vasoactive drugs were used for 77.19% of patients. Factors independently associated with it were qSOFA score ≥2, increase of SOFA score over the first 48 h, mechanical ventilation on the first day in ICU, need for colistin therapy, lower arterial pH on arrival to ICU. Cut-off value of the noradrenaline dose associated with ICU mortality was 0.21 μg/kg/min with a ROC of 0.9686 (95% CI 0.93-1.00, p < 0.0001). Conclusions: Mortality of oncohematological patients in the ICU is high and it is associated with progression of organ dysfunction over the first 48 h in ICU, invasive mechanical ventilation and need for relatively low dose of noradrenaline. Despite our findings, we do not recommend making decisions regarding treatment limitations for patients who have reached cut-off dose of noradrenaline.
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Affiliation(s)
- Šarūnas Judickas
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu Str. 2, 08661 Vilnius, Lithuania; (M.Š.); (J.Š.)
- Correspondence:
| | - Raimundas Stasiūnaitis
- Faculty of Medicine, Vilnius University, M. K. Čiurlionio Str. 21/27, 03101 Vilnius, Lithuania;
| | - Andrius Žučenka
- Clinic of Internal Diseases, Family Medicine and Oncology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu Str. 2, 08661 Vilnius, Lithuania;
| | - Tadas Žvirblis
- Department of Mechanics and Material Engineering, Faculty of Mechanics, Vilnius Gediminas Technical University Vilnius, J. Basanaviciaus Str. 28, 03224 Vilnius, Lithuania;
| | - Mindaugas Šerpytis
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu Str. 2, 08661 Vilnius, Lithuania; (M.Š.); (J.Š.)
| | - Jūratė Šipylaitė
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Santariskiu Str. 2, 08661 Vilnius, Lithuania; (M.Š.); (J.Š.)
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28
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Patel A, Murthy GSG, Hamadani M, Szabo A, Knight JM. The impact of beta-blocker use at the time of hematopoietic cell transplantation on the development of acute and chronic graft-versus-host disease. Hematol Oncol Stem Cell Ther 2021; 16:209-216. [PMID: 34780786 DOI: 10.1016/j.hemonc.2021.10.001] [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: 06/08/2021] [Revised: 07/27/2021] [Accepted: 10/14/2021] [Indexed: 11/19/2022] Open
Abstract
Sympathetic nervous system activation plays a role in the development of acute and chronic graft-versus-host disease (GVHD) following allogeneic hematopoietic cell transplantation (HCT). The primary objective was to compare the cause-specific hazard of grade II-IV and III-IV acute GVHD (aGVHD) and chronic GVHD (cGVHD) in the context of ß-blocker use and type (selective vs. non-selective). Secondary objectives included overall survival (OS), relapse-free survival (RFS), and cumulative incidence of relapse, non-relapse mortality (NRM), and grade II-IV and III-IV aGVHD and cGVHD. The current study included 151 patients ages 18 and older diagnosed with hematological malignancies who underwent reduced intensity conditioning allogeneic HCT from HLA matched related or unrelated donors between January 2014 and 2017. 31 patients were on a ß-blocker of which 71% were on a selective ß-blocker. The incidence of aGVHD was not different among groups. Results show a non-significant trend in the association between ß-blocker use and reduction in the risk of developing cGVHD (cause-specific hazard ratio 0.49, p = 0.060), with no negative impact on survival or relapse. The current data are supportive of a potential ß-adrenergic influence on the pathogenesis of GVHD, consistent with the inflammatory etiology of GVHD and the anti-inflammatory effects of ß-adrenergic antagonists.
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Affiliation(s)
- Arjun Patel
- Medical College of Wisconsin, Milwaukee, WI, United States
| | | | - Mehdi Hamadani
- BMT and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Jennifer M Knight
- Departments of Psychiatry, Medicine, and Microbiology & Immunology, Medical College of Wisconsin, Milwaukee, WI, United States
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Improved Therapeutic Approaches are Needed to Manage Graft-versus-Host Disease. Clin Drug Investig 2021; 41:929-939. [PMID: 34657244 PMCID: PMC8556206 DOI: 10.1007/s40261-021-01087-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/25/2022]
Abstract
Allogeneic haematopoietic stem cell transplantation (alloHSCT) offers a potentially curative therapy for patients suffering from diseases of the haematopoietic system but requires a high level of expertise and is both resource intensive and expensive. A frequent and life-threatening complication is graft-versus-host disease (GvHD). Acute GvHD (aGvHD) generally causes skin, gastrointestinal and liver symptoms, but chronic GvHD (cGvHD) has a different pathophysiology and may affect nearly every organ or tissue of the body. In Europe, GvHD prophylaxis is generally a calcineurin inhibitor in combination with methotrexate, with high-dose systemic steroids used for advanced GvHD treatment. Between 39% and 59% of alloHSCT patients will develop aGvHD and around 36–37% will develop cGvHD. Steroid response decreases with increasing disease severity, which in turn leads to an increase in non-relapse mortality. GvHD imposes a financial burden on healthcare systems, significantly increasing post-alloHSCT costs. Increased GvHD disease severity magnifies this. Balancing immunosuppression to control the GvHD whilst maintaining a degree of immunocompetence against infection is critical. European GvHD guidelines acknowledge the lack of evidence to support a standard second-line therapy, and improved long-term outcomes and quality-of-life (QoL) remain an unmet need. Evidence generation for potential treatments is challenging. Issues to overcome include choice of comparator (extensive off-label usage); blinding; selection of relevant patient-reported outcome measures (PROMs); and rarity of the condition, which may infeasibly increase timescales to achieve clinical and statistical relevance.
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Wang W, Yang N, Yang YH, Wen R, Liu CF, Zhang TN. Non-Coding RNAs: Master Regulators of Inflammasomes in Inflammatory Diseases. J Inflamm Res 2021; 14:5023-5050. [PMID: 34616171 PMCID: PMC8490125 DOI: 10.2147/jir.s332840] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
Emerging data indicates that non-coding RNAs (ncRNAs) represent more than just “junk sequences” of the genome and have been found to be involved in multiple diseases by regulating various biological process, including the activation of inflammasomes. As an important aspect of innate immunity, inflammasomes are large immune multiprotein complexes that tightly regulate the production of pro-inflammatory cytokines and mediate pyroptosis; the activation of the inflammasomes is a vital biological process in inflammatory diseases. Recent studies have emphasized the function of ncRNAs in the fine control of inflammasomes activation either by directly targeting components of the inflammasomes or by controlling the activity of various factors that control the activation of inflammasomes; consequently, ncRNAs may represent potential therapeutic targets for inflammatory diseases. Understanding the precise role of ncRNAs in controlling the activation of inflammasomes will help us to design targeted therapies for multiple inflammatory diseases. In this review, we summarize the regulatory role and therapeutic potential of ncRNAs in the activation of inflammasomes by focusing on a range of inflammatory diseases, including microbial infection, sterile inflammatory diseases, and fibrosis-related diseases. Our goal is to provide new ideas and perspectives for future research.
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Affiliation(s)
- Wei Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Ni Yang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Yu-Hang Yang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Ri Wen
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Chun-Feng Liu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Tie-Ning Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
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31
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Farhadfar N, Leather HL, Wang S, Burton N, IrizarryGatell V, Itzler R, Salloum RG, Wingard JR. Severity of Acute Graft-versus-Host Disease and Associated Healthcare Resource Utilization, Cost, and Outcomes. Transplant Cell Ther 2021; 27:1007.e1-1007.e8. [PMID: 34537422 DOI: 10.1016/j.jtct.2021.09.004] [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: 05/31/2021] [Revised: 08/21/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
Acute graft-versus-host disease (aGVHD) contributes to poor outcomes and increased healthcare resource utilization (HRU) after allogeneic hematopoietic stem cell transplantation (HCT). However, HRU and the economic burden of aGVHD based on severity of the disease is not well characterized. Our study cohort comprised 290 adults who underwent allogeneic HCT between 2010 and 2018. Costs, HRU, and all-cause mortality in the 100-day and 365-day periods after HCT were compared between patients with aGVHD and those without aGVHD. The impact of aGVHD severity and gastrointestinal (GI) involvement on mortality, HRU, and economic burden was also evaluated. Medical costs and total hospital length of stay (LOS) were retrieved from administrative data that allocate costs to services based on departmental input for resource use and were adjusted to 2018 dollars. The Wilcoxon rank-sum test was used to compare the number of inpatient days and total costs. Multivariable linear regression was fitted on log-transformed costs. Compared with patients without aGVHD, those with aGVHD had a significantly greater median hospital LOS (28 days versus 22 days) and higher rates of intensive care unit (ICU) admission (13% versus 6%) and rehospitalization (59% versus 38%) during the first 100 days post-HCT. The presence of grade I-II aGVHD significantly prolonged the hospital LOS by a median of 3 days and increased the readmission rate by 18%, whereas grade III-IV aGVHD was associated with a nearly 30% increase in the readmission rate and a doubling of inpatient LOS, ICU admission rate, and mortality in the first 100 days post-HCT. Compared with the absence of aGVHD, lower GI involvement in aGVHD was also associated with increased risk of readmission (30%) and twice as many inpatient days, doubling the likelihood of ICU admission and mortality over the first 100 days. Similar findings were observed over days 101 to 365 post-HCT. The mean cost attributable to aGVHD regardless of grade was $60,923 in the first 100 days post-HCT. This cost varied by grade. The mean aGVHD- attributable costs were $18,071 for grade I, $36,115 for grade II and $120,929 for grade III/IV aGVHD and $114,668 for aGVHD involving the lower GI tract. In the 101- to 365-day period, the mean attributable aGVHD cost regardless of grade was $17,527. This cost also varied by grade. There were no additional aGVHD-attributable costs for grade I, but the mean aGVHD-attributable costs were $9743 for grade II, $62,220 for grade III/IV, and $55,724 for aGVHD with lower GI involvement compared with the controls without aGVHD. High-grade aGVHD and GI involvement in aGVHD, especially lower GI aGVHD, is associated with a considerably increased mortality and healthcare economic burden. Therefore, it is imperative that new therapeutic strategies be developed for this patient population.
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Affiliation(s)
- Nosha Farhadfar
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610.
| | - Helen L Leather
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610
| | - Shu Wang
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610
| | - Nathan Burton
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610
| | - Vivian IrizarryGatell
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610
| | - Robbin Itzler
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610
| | - Ramzi G Salloum
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610
| | - John R Wingard
- University of Florida College of Medicine, 1600 SW Archer Road, Gainesville, FL 32610
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Kreft A, Hippe K, Wagner-Drouet EM, Ries I, Kandulski A, Büttner-Herold M, Neumann H, Weber D, Holler E, Schindeldecker M. An investigation of the diagnostic, predictive, and prognostic impacts of three colonic biopsy grading systems for acute graft versus host disease. PLoS One 2021; 16:e0256543. [PMID: 34437603 PMCID: PMC8389423 DOI: 10.1371/journal.pone.0256543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/09/2021] [Indexed: 11/19/2022] Open
Abstract
Acute graft versus host disease (aGvHD) is an important, life-threatening complication after allogeneic hematopoietic stem cell transplantation (alloHSCT). To investigate the value of multiple simultaneous colon biopsies in improving diagnostic accuracy in patients with aGvHD, we retrospectively analyzed 157 patients after alloHSCT. The biopsies were evaluated individually using three established histological grading systems (Lerner, Sale, and Melson). The maximum, minimum, median, and mean histological aGvHD grades were calculated for each patient, and the results were correlated with the Glucksberg grade of clinical manifestation of GvHD, steroid therapy status, and outcome. We found that multiple colon biopsies enhanced diagnostic sensitivity. Moreover, higher histological grades correlated with steroid therapy initiation and refractoriness; the latter particularly occurred when advanced damage was present in all samples and healthy colon mucosa was reduced or absent. On multivariate analysis, the minimal Lerner and Glucksberg grades for intestinal aGvHD were significantly associated with steroid treatment failure. Ninety-nine patients died. The median survival was 285 days after the biopsies were taken. Fifteen patients died from relapse of their underling disorder and 84 from other causes, mostly infection (53 patients) and GvHD (14 patients). Multivariate analysis revealed a significant association between none-relapse mortality and the mean Lerner grade, minimum Melson grade, Glucksberg organ stage, and platelet counts. Thus, we found the Lerner system to be superior to the other grading methods in most instances and histologic evaluation of multiple simultaneously obtained biopsies from the colon to result in a higher diagnostic yield, which helps plan systemic steroid treatment while predicting treatment response and outcome.
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Affiliation(s)
- Andreas Kreft
- Institute of Pathology, University Medical Center Mainz, Mainz, Germany
- * E-mail:
| | - Katrin Hippe
- Institute of Pathology, University Hospital Regensburg, Regensburg, Germany
| | - Eva Maria Wagner-Drouet
- 3 Medical Department, Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Isabelle Ries
- 3 Medical Department, Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Arne Kandulski
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Erlangen, Germany
| | - Helmut Neumann
- 1 Medical Department, University Medical Center Mainz, Mainz, Germany
| | - Daniela Weber
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Ernst Holler
- Department of Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Mario Schindeldecker
- Institute of Pathology, University Medical Center Mainz, Mainz, Germany
- Tissue Biobank, University Medical Center Mainz, Mainz, Germany
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Spector LG, Spellman SR, Thyagarajan B, Beckman KB, Hoffmann C, Garbe J, Hahn T, Sucheston-Campbell L, Richardson M, De For TE, Tolar J, Verneris MR. Neither Donor nor Recipient Mitochondrial Haplotypes Are Associated with Unrelated Donor Transplant Outcomes: A Validation Study from the CIBMTR. Transplant Cell Ther 2021; 27:836.e1-836.e7. [PMID: 34174468 DOI: 10.1016/j.jtct.2021.06.019] [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: 04/14/2021] [Revised: 06/04/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022]
Abstract
Graft-versus-host-disease (GVHD) is a multistep process that involves T-cell recognition and priming toward alloantigen, expansion, acquisition of effector function, and repeated tissue injury, resulting in clinical manifestations of the disease. All of these processes have considerable metabolic demands and understanding the key role of mitochondria in cellular metabolism as it relates to GVHD has increased significantly. Mitochondrial DNA (mtDNA) haplotypes have been linked to functional differences in vitro, suggesting they have functional differences at an organismal level. We previously used mtDNA typing to assess the impact of mtDNA haplotypes on outcomes of ~400 allo-HCT patients. This pilot study identified uncommon mtDNA haplotypes potentially associated with inferior outcomes. We sought to validate pilot findings of associations between donor and recipient mitochondrial haplotypes and transplant outcome. We examined a cohort of 4143 donor-recipient pairs obtained from the Center for International Blood and Marrow Transplant Research. MtDNA was extracted from whole blood or peripheral blood mononuclear cells from donors and recipients and sequenced to discern haplotype. We used multiple regression analysis to examine the independent association of mtDNA haplotype with overall survival and grade III-IV acute GVHD (aGVHD) adjusting for known risk factors for poor transplant outcome. Neither recipient nor donor mtDNA haplotype reached groupwise significance for overall survival (P =.26 and .39, respectively) or grade III-IV aGVHD (P = .68 and.57, respectively). Adjustment for genomically determined ancestry in the subset of donor-recipient pairs for which this was available did not materially change results. We conclude that our original finding was due to chance in a small sample size and that there is essentially no evidence that mtDNA haplotype or haplotype mismatch contributes to risk of serious outcomes after allogeneic transplantation.
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Affiliation(s)
- Logan G Spector
- Division of Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota.
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
| | - Bharat Thyagarajan
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Kenneth B Beckman
- University of Minnesota Genomics Center, University of Minnesota, Minneapolis, Minnesota
| | - Cody Hoffmann
- University of Minnesota Genomics Center, University of Minnesota, Minneapolis, Minnesota
| | - John Garbe
- University of Minnesota Genomics Center, University of Minnesota, Minneapolis, Minnesota
| | - Theresa Hahn
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | | | - Michaela Richardson
- Division of Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd E De For
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Jakub Tolar
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Michael R Verneris
- University of Colorado Denver, Children's Cancer and Blood Disorders, Denver, Colorado
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Heidrich V, Bruno JS, Knebel FH, de Molla VC, Miranda-Silva W, Asprino PF, Tucunduva L, Rocha V, Novis Y, Arrais-Rodrigues C, Fregnani ER, Camargo AA. Dental Biofilm Microbiota Dysbiosis Is Associated With the Risk of Acute Graft- Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2021; 12:692225. [PMID: 34220852 PMCID: PMC8250416 DOI: 10.3389/fimmu.2021.692225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 01/04/2023] Open
Abstract
Acute graft-versus-host disease (aGVHD) is one of the major causes of death after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Recently, aGVHD onset was linked to intestinal microbiota (IM) dysbiosis. However, other bacterial-rich gastrointestinal sites, such as the mouth, which hosts several distinctive microbiotas, may also impact the risk of GVHD. The dental biofilm microbiota (DBM) is highly diverse and, like the IM, interacts with host cells and modulates immune homeostasis. We characterized changes in the DBM of patients during allo-HSCT and evaluated whether the DBM could be associated with the risk of aGVHD. DBM dysbiosis during allo-HSCT was marked by a gradual loss of bacterial diversity and changes in DBM genera composition, with commensal genera reductions and potentially pathogenic bacteria overgrowths. High Streptococcus and high Corynebacterium relative abundance at preconditioning were associated with a higher risk of aGVHD (67% vs. 33%; HR = 2.89, P = 0.04 and 73% vs. 37%; HR = 2.74, P = 0.04, respectively), while high Veillonella relative abundance was associated with a lower risk of aGVHD (27% vs. 73%; HR = 0.24, P < 0.01). Enterococcus faecalis bloom during allo-HSCT was observed in 17% of allo-HSCT recipients and was associated with a higher risk of aGVHD (100% vs. 40%; HR = 4.07, P < 0.001) and severe aGVHD (60% vs. 12%; HR = 6.82, P = 0.01). To the best of our knowledge, this is the first study demonstrating that DBM dysbiosis is associated with the aGVHD risk after allo-HSCT.
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Affiliation(s)
- Vitor Heidrich
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil.,Departamento de Bioquímica, Instituto de Química, Universidade de São Paulo, São Paulo, Brazil
| | - Julia S Bruno
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Franciele H Knebel
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Vinícius C de Molla
- Centro de Oncologia, Hospital Sírio-Libanês, São Paulo, Brazil.,Departamento de Oncologia Clínica e Experimental, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Paula F Asprino
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
| | | | - Vanderson Rocha
- Centro de Oncologia, Hospital Sírio-Libanês, São Paulo, Brazil.,Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo/Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, Brazil.,Churchill Hospital, National Health Service Blood and Transplant, Oxford, United Kingdom
| | - Yana Novis
- Centro de Oncologia, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Celso Arrais-Rodrigues
- Centro de Oncologia, Hospital Sírio-Libanês, São Paulo, Brazil.,Departamento de Oncologia Clínica e Experimental, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Anamaria A Camargo
- Centro de Oncologia Molecular, Hospital Sírio-Libanês, São Paulo, Brazil
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Curnow E, Hughes RA, Birnie K, Crowther MJ, May MT, Tilling K. Multiple imputation strategies for a bounded outcome variable in a competing risks analysis. Stat Med 2021; 40:1917-1929. [PMID: 33469974 PMCID: PMC8611803 DOI: 10.1002/sim.8879] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 09/04/2020] [Accepted: 12/29/2020] [Indexed: 01/23/2023]
Abstract
In patient follow-up studies, events of interest may take place between periodic clinical assessments and so the exact time of onset is not observed. Such events are known as "bounded" or "interval-censored." Methods for handling such events can be categorized as either (i) applying multiple imputation (MI) strategies or (ii) taking a full likelihood-based (LB) approach. We focused on MI strategies, rather than LB methods, because of their flexibility. We evaluated MI strategies for bounded event times in a competing risks analysis, examining the extent to which interval boundaries, features of the data distribution and substantive analysis model are accounted for in the imputation model. Candidate imputation models were predictive mean matching (PMM); log-normal regression with postimputation back-transformation; normal regression with and without restrictions on the imputed values and Delord and Genin's method based on sampling from the cumulative incidence function. We used a simulation study to compare MI methods and one LB method when data were missing at random and missing not at random, also varying the proportion of missing data, and then applied the methods to a hematopoietic stem cell transplantation dataset. We found that cumulative incidence and median event time estimation were sensitive to model misspecification. In a competing risks analysis, we found that it is more important to account for features of the data distribution than to restrict imputed values based on interval boundaries or to ensure compatibility with the substantive analysis by sampling from the cumulative incidence function. We recommend MI by type 1 PMM.
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Affiliation(s)
- Elinor Curnow
- Department of Statistics and Clinical StudiesNHS Blood and TransplantBristolUK
- Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Rachael A. Hughes
- Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
- MRC Integrative Epidemiology UnitUniversity of BristolBristolUK
| | - Kate Birnie
- Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
- MRC Integrative Epidemiology UnitUniversity of BristolBristolUK
| | - Michael J. Crowther
- Biostatistics Research Group, Department of Health SciencesUniversity of Leicester, George Davies CentreLeicesterUK
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Margaret T. May
- Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Kate Tilling
- Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
- MRC Integrative Epidemiology UnitUniversity of BristolBristolUK
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36
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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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Tremblay G, Tomaras D, Strati E, Forsythe A. Comparative Effectiveness of Remestemcel-L-rknd versus Ruxolitinib in Pediatric Patients with Steroid-Refractory Acute Graft-Versus-Host Disease using Simulated Treatment Comparisons. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2021; 8:10-17. [PMID: 33768123 PMCID: PMC7983491 DOI: 10.36469/jheor.2021.19008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 01/20/2021] [Indexed: 06/12/2023]
Abstract
Background: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) can be a lifesaving treatment for hematologic malignancies, but acute graft-versus-host-disease (aGVHD) is a potentially deadly adverse effect experienced by up to half of allo-HSCT recipients. Inadequate response to steroid therapy for aGVHD is associated with poor prognosis and high mortality, including among pediatric patients, who are the focus of this study. Ruxolitinib and remestemcel-L-rknd were evaluated for the treatment of steroid-refractory (SR) aGVHD in two separate single-arm trials. To effectively compare the safety and efficacy of these treatments without a head-to-head trial, a simulated treatment comparison (STC) was conducted. Methods: Regression techniques were used to adjust individual patient-level data from the remestemcel-L-rknd trial to mutually reported baseline characteristics from the ruxolitinib trial. Outcomes of interest included a 28-day overall response rate (ORR), a 28-day ORR in the grade III-IV aGVHD population, and adverse events (AEs). Results: In the full populations, the STC of risk ratios (RRs) found treatment with remestemcel-L-rknd to be associated with a numerical but not statistically significant improvement in the 28-day ORR versus ruxolitinib. In the grade III-IV aGVHD sub-group, the STC showed significantly improved 28-day ORR for remestemcel-L-rknd versus ruxolitinib (P=0.04). Remestemcel-L-rknd was also associated with improved safety outcomes (P<0.05) in 17 out of 30 AEs, including hematologic events, peripheral edema, muscular weakness, nausea, back pain, and fatigue. Conclusion: Remestemcel-L-rknd was associated with significant improvements in day 28 ORR compared with ruxolitinib in patients with severe (grade III-IV) SR aGVHD. Across all grades of SR aGVHD, remestemcel-L-rknd was associated with fewer all-grade treatment-emergent adverse events (TEAEs) (27/30) available for comparison, including the majority reaching statistical significance.
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38
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[Bone marrow transplantation patients in the intensive care unit]. Med Klin Intensivmed Notfmed 2021; 116:111-120. [PMID: 33564899 PMCID: PMC7871956 DOI: 10.1007/s00063-021-00782-8] [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: 10/26/2020] [Revised: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 10/31/2022]
Abstract
Allogeneic hematopoetic stem cell transplantation yields improved long-term survival for patients with high-risk malignant and non-malignant hematologic disease. However, it is associated with high morbidity and mortality. A proportion of patients need intensive care due to infectious, immunological and/or toxic complications. The utility of intensive care unit (ICU) treatments as mechanical ventilation and renal replacement therapy for these patients is uncertain since mortality is high. We describe the most frequent complications and the treatment options concerning the ICU in recipients of allogeneic hematopoetic stem cells.
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Abstract
Acute graft-versus-host disease (GVHD), the major complication after allogeneic hematopoietic cell transplant (HCT), develops in approximately 50% of patients. The primary treatment is high-dose systemic steroids, but treatment failure is common, and steroid-refractory (SR) GVHD is the leading cause of non-relapse mortality after allogeneic HCT. Ruxolitinib became the first treatment for SR GVHD to obtain US Food and Drug Administration approval, and other new treatments are actively being studied. We searched the literature using the PubMed database and clinical trials using ClinicalTrials.gov to identify the most promising new treatments for GVHD. In this review, we categorize potential new treatments for GVHD by their mechanism of action (e.g., antibodies that deplete T cells or prevent their trafficking to target tissues, proteasome inhibitors, tyrosine kinase inhibitors, and other agents) and summarize the results from clinical trials.
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Affiliation(s)
- Stelios Kasikis
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - Aaron Etra
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA
| | - John E Levine
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, NY, USA.
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40
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Steinbrunn T, Zovko J, Kraus S. JAK-Inhibitoren für die Behandlung hämatoonkologischer Erkrankungen. AKTUEL RHEUMATOL 2020. [DOI: 10.1055/a-1285-4125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ZusammenfassungDie konstitutive Aktivierung des JAK-STAT-Signalwegs ist charakteristisch für die Pathogenese der myeloproliferativen Neoplasien, speziell der primären Myelofibrose, der Polycythaemia vera und der essentiellen Thrombozythämie. Die Einführung von oral verfügbaren JAK-Inhibitoren in die Klinik brachte einen entscheidenden Fortschritt für die pharmakologische Behandlung der Myelofibrose und der Polycythaemia vera, wenngleich damit noch keine Heilung verbunden ist. Im Vordergrund steht die Verbesserung der Lebensqualität der meist älteren Patienten durch Kontrolle krankheitsbedingter konstitutioneller Symptome, Reduktion einer bestehenden Splenomegalie und Vermeidung insbesondere von thromboembolischen Folgekomplikationen. Darüber hinaus kann die Therapie von Myelofibrose-Patienten mit JAK-Inhibitoren jedoch auch deren Krankheitsverlauf verlangsamen und ihr Gesamtüberleben verlängern. Der bislang einzige in Europa zugelassene JAK-Inhibitor Ruxolitinib hemmt die Isoformen JAK1 und JAK2 und besitzt sowohl antiinflammatorisches als auch antiproliferatives Potenzial. Damit zeigt dieser Inhibitor überdies eine gute Wirkung in der Therapie der Graft-versus-Host-Erkrankung nach allogener hämatopoetischer Stammzelltransplantation. Mit Fedratinib, Pacritinib und Momelatinib befinden sich derzeit 3 weitere vielversprechende JAK-Inhibitoren mit etwas unterschiedlichen Wirkprofilen in der klinischen Phase III-Testung. Diese zeigen auch bei Patienten mit unwirksamer oder unverträglicher Vorbehandlung mit Ruxolitinib Wirksamkeit, sodass eine kontinuierliche Weiterentwicklung der entsprechenden Therapiestrategien abzusehen ist.
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Affiliation(s)
- Torsten Steinbrunn
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg
| | - Josip Zovko
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg
| | - Sabrina Kraus
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Würzburg, Würzburg
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Fornwalt RA, Brigham EP, Scott Stephens R. Critical Care of Hematopoietic Stem Cell Transplant Patients. Crit Care Clin 2020; 37:29-46. [PMID: 33190774 DOI: 10.1016/j.ccc.2020.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Life-threatening complications are frequent after hematopoietic stem cell transplant (HSCT), and optimum critical care is essential to ensuring good outcomes. The immunologic consequences of HSCT result in a markedly different host response to critical illness. Infection is the most common cause of critical illness but noninfectious complications are frequent. Respiratory failure or sepsis are the typical presentations but the sequelae of HSCT can affect nearly any organ system. Pattern recognition can facilitate anticipation and early intervention in post-HSCT critical illness. HSCT critical care is a multidisciplinary endeavor. Continued investigation and focus on process improvement will continue to improve outcomes.
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Affiliation(s)
- Rachael A Fornwalt
- Oncology Intensive Care Unit, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Hospital, Harry and Jeanette Weinberg Building, Pod 5C, 401 North Broadway, Baltimore, MD 21231, USA
| | - Emily P Brigham
- Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - R Scott Stephens
- Oncology Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Oncology, Johns Hopkins University, 1800 Orleans Street, Suite 9121 Zayed Tower, Baltimore, MD 21287, USA.
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Vedolizumab for prevention of graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Blood Adv 2020; 3:4136-4146. [PMID: 31821456 DOI: 10.1182/bloodadvances.2019000893] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/31/2019] [Indexed: 12/21/2022] Open
Abstract
Acute graft-versus-host disease (aGVHD) remains a significant complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Vedolizumab could help prevent aGVHD by inhibiting the migration of both naive and activated lymphocytes into gut-associated lymphoid tissues and the lamina propria. We carried out a phase 1b, open-label, dose-finding study in adults undergoing allo-HSCT to evaluate the tolerability, safety, and pharmacokinetics of vedolizumab, and its effectiveness in reducing aGVHD. IV vedolizumab was administered on day -1, +13, and +42 with respect to allo-HSCT, starting at 75 mg and with dose escalation guided by tolerability and pharmacokinetics. A total of 24 participants was enrolled, and no dose-limiting toxicities were observed in either the 75-mg cohort (n = 3) or the dose-escalated 300-mg cohort (n = 21). Treatment-emergent adverse events related to vedolizumab occurred in 8 participants. Overall, 4 deaths occurred during the 12 months following allo-HSCT. No participants in the 75-mg cohort developed modified Glucksberg grade II to IV aGVHD by 100 days after allo-HSCT. Four participants (19.0%) in the 300-mg cohort developed grade II to IV aGVHD by 100 days after allo-HSCT, including 3 participants who developed stage 1 aGVHD of the lower-intestinal tract. Vedolizumab IV 300 mg was well tolerated as aGVHD prevention, and the incidence of overall and lower-intestinal aGVHD was low. These findings support further evaluation of vedolizumab in this patient population. This trial was registered at www.clinicaltrials.gov as #NCT02728895.
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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: 2] [Impact Index Per Article: 0.5] [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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Kurtzberg J, Prockop S, Chaudhury S, Horn B, Nemecek E, Prasad V, Satwani P, Teira P, Hayes J, Burke E. Study 275: Updated Expanded Access Program for Remestemcel-L in Steroid-Refractory Acute Graft-versus-Host Disease in Children. Biol Blood Marrow Transplant 2020; 26:855-864. [PMID: 32044400 PMCID: PMC8292970 DOI: 10.1016/j.bbmt.2020.01.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 01/08/2023]
Abstract
Clinical outcomes in children with steroid-refractory acute graft-versus-host disease (SR-aGVHD) are generally poor, with a high mortality rate and limited therapeutic options. Here we report our updated investigational experience with mesenchymal stromal cell (MSC) therapy with remestemcel-L in a multicenter expanded access protocol (ClinicalTrials.gov identifier NCT00759018) in 241 children with aGVHD who failed to respond to steroids with or without other secondary and tertiary immunosuppressive therapies. A total of 241 children with grade B-D SR-aGVHD were enrolled at 50 sites in 8 countries and received 8 biweekly i.v. infusions of human MSCs, 2 × 106 per kg for 4 weeks, with an option for an additional 4 weekly infusions after day +28 for subjects who achieved either a partial response (PR) or mixed response. The mean age of the subjects was 9.6 years; 39% were female, and 60% were white. Most of the subjects had grade C (30%) or grade D (50%) disease, and in most cases, the subjects had failed to respond to other immunosuppressive agents after failing steroids. The primary endpoint was overall response (OR; the sum of complete response [CR] and PR) at day +28. Across all subjects, a 28-day OR was observed in 157 patients (65.1%), with 34 (14.1%) achieving CR and 123 (51.3%) achieving PR. Stratified by aGVHD grade at baseline, the OR rate at day +28 was 72.9% for patients with aGVHD grade B, 67.1% for those with aGVHD grade C, and 60.8% for those with aGVHD grade D. Survival through day +100, a secondary endpoint of the study, was 66.9% (n = 160 of 239). Importantly, survival through day +100 was significantly greater in subjects who achieved a day +28 OR compared with nonresponders (82.1% versus 38.6%; P < .001, log-rank test). Remestemcel-L safety was generally well tolerated, with no infusional toxicity and no identified safety concerns. In summary, this update to the remestemcel-L expanded access program confirms the reported clinical and survival benefits of remestemcel-L therapy in children with aGVHD who have exhausted all conventional therapeutic options.
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Affiliation(s)
| | - Susan Prockop
- MSK Kids Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sonali Chaudhury
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Eneida Nemecek
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Vinod Prasad
- Duke University Medical Center, Durham, North Carolina
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45
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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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46
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Healthcare resource utilization and costs associated with acute graft-versus-host disease following allogeneic hematopoietic cell transplantation. Support Care Cancer 2020; 28:5491-5499. [DOI: 10.1007/s00520-020-05382-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 02/26/2020] [Indexed: 11/24/2022]
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47
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Epperla N, Li A, Logan B, Fretham C, Chhabra S, Aljurf M, Chee L, Copelan E, Freytes CO, Hematti P, Lazarus HM, Litzow M, Nishihori T, Olsson RF, Prestidge T, Saber W, Wirk B, Yared JA, Loren A, Pasquini M. Incidence, Risk Factors for and Outcomes of Transplant-Associated Thrombotic Microangiopathy. Br J Haematol 2020; 189:1171-1181. [PMID: 32124435 DOI: 10.1111/bjh.16457] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 12/14/2022]
Abstract
Transplant-associated thrombotic microangiopathy (TA-TMA) is a complication of allogeneic transplantation (allo-HCT). The incidence and risk factors associated with TA-TMA are not well known. A retrospective analysis from the Center for International Blood and Marrow Transplant Research (CIBMTR) was conducted including patients receiving allo-HCT between 2008 and 2016, with the primary objective of evaluating the incidence of TA-TMA. Secondary objectives included identification of risk factors associated with TA-TMA, and the impact of TA-TMA on overall survival and the need for renal replacement therapy (RRT). Among 23,665 allo-HCT recipients, the 3-year cumulative incidence of TA-TMA was 3%. Variables independently-associated with increased incidence of TA-TMA included female sex, prior autologous transplant, primary disease (acute lymphoblastic leukaemia and severe aplastic anaemia), donor type (mismatched or unrelated donor), conditioning intensity (myeloablative), GVHD prophylaxis (sirolimus + calcineurin inhibitor), pre-transplant kidney dysfunction and acute GVHD (time-varying effect). TA-TMA was associated with higher mortality (HR = 3·1, 95% Confidence Interval [CI] = 2·8-16·3) and RRT requirement (HR = 7·1, 95% CI = 5·7-311·6). This study provides epidemiologic data on TA-TMA and its impact on transplant outcomes. Increased awareness of the risk factors will enable providers to be vigilant of this uncommon but serious transplant complication. The results will also provide benchmarking for future study designs and comparisons.
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Affiliation(s)
- Narendranath Epperla
- Division of Hematology, Department of Medicine, The James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH
| | - Ang Li
- University of Washington, Seattle, WA
| | - Brent Logan
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Caitrin Fretham
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Saurabh Chhabra
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Lynette Chee
- Royal Melbourne Hospital City Campus, Victoria, Australia
| | - Edward Copelan
- Levine Cancer Institute, Atrium Health, Carolinas HealthCare System, Charlotte, NC
| | | | - Peiman Hematti
- Division of Hematology/Oncology/Bone Marrow Transplantation, Department of Medicine, University of Wisconsin, Madison, WI
| | | | - Mark Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, MN
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, FL
| | - Richard F Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm.,Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Wael Saber
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Baldeep Wirk
- Division of Bone Marrow Transplant, Seattle Cancer Care Alliance, Seattle, WA
| | - Jean A Yared
- Blood & Marrow Transplantation Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Alison Loren
- Division of Hematology/Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Prophylaxis and management of graft versus host disease after stem-cell transplantation for haematological malignancies: updated consensus recommendations of the European Society for Blood and Marrow Transplantation. LANCET HAEMATOLOGY 2020; 7:e157-e167. [PMID: 32004485 DOI: 10.1016/s2352-3026(19)30256-x] [Citation(s) in RCA: 283] [Impact Index Per Article: 70.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 01/02/2023]
Abstract
Graft-versus-host disease (GVHD) is a major factor contributing to mortality and morbidity after allogeneic stem-cell transplantation. Because of the small number of results from well designed, large-scale, clinical studies there is considerable variability in the prevention and treatment of GVHD worldwide. In 2014, to standardise treatment approaches the European Society of Blood and Marrow Transplantation published recommendations on the management of GVHD in the setting of HLA-identical sibling or unrelated donor transplantation in adult patients with haematological malignancies. Here we update these recommendations including the results of study published after 2014. Evidence was searched in three steps: first, a widespread scan of published trials, meta-analyses, and systematic reviews; second, expert opinion was added for specific issues following several rounds of debate; and third, a refined search to target debated or rapidly updating issues. On the basis of this evidence and the 2014 recommendations, five members of the EBMT Transplant Complications Working Party created 38 statements on GVHD prophylaxis, drug management, and treatment of acute and chronic GVHD. Subsequently, they created the EBMT GVHD management recommendation expert panel by recruiting 20 experts with expertise in GVHD management. An email-based, two-round Delphi panel approach was used to manage the consensus. Modified National Comprehensive Cancer Network categories for evidence and consensus were applied to the approved statements. We reached 100% consensus for 29 recommendations and 95% consensus for nine recommendations. Key updates to these recommendations include a broader use of rabbit anti-T-cell globulin; lower steroid doses for the management of grade 2 acute GVHD with isolated skin or upper gastrointestinal tract manifestations; fluticasone, azithromycin, and montelukast should be used for bronchiolitis obliterans syndrome; and the addition of newer treatment options for resteroid-refractory acute and chronic GVHD. In addition, we discuss specific aspects of GVHD prophylaxis and management in the setting of haploidentical transplantation and in paediatric patients, but no formal recommendations on those procedures have been provided in this Review. The European Society of Blood and Marrow Transplantation proposes to use these recommendations as a basis for the routine management of GVHD during stem-cell transplantation.
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Hashmi H, Bhandari S, Dhanoa J, Wu X, Rai S, Figg L, Baize T, Krem M, Hegazi M, Emmons R. Clinical Outcomes Using Mycophenolate and Tacrolimus for Graft-versus-Host Disease Prophylaxis in Patients Undergoing Allogeneic Stem Cell Transplant: A Single Institution Experience. Cureus 2020; 12:e6893. [PMID: 32190456 PMCID: PMC7058400 DOI: 10.7759/cureus.6893] [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] [Indexed: 11/05/2022] Open
Abstract
For recipients of allogeneic hematopoietic stem cell transplant (HSCT), mycophenolate mofetil (MMF) plus tacrolimus combination is mostly used in reduced-intensity (RIC), and nonmyeloablative conditioning (NMAC) whereas methotrexate and tacrolimus combination is preferred in myeloablative conditioning (MAC). We present single institution outcomes in patients undergoing allogeneic HSCT with both MAC and NMAC/RIC regimen using MMF and tacrolimus for graft-versus-host disease (GVHD) prophylaxis. Data from all adult patients who underwent allogeneic HSCT from 2007 to 2017 was collected from Data Back to Centers web-based application of Center for International Blood and Marrow Transplant Research (CIBMTR). A total of 150 patients were included with the mean age of 46.9 years. For the patients who received MAC (n=109), the cumulative incidence of grade II-IV acute GVHD at day 100 was 37%, grade II-IV acute GVHD at one year was 51%, and chronic GVHD at one year was 38%. For the patients who received NMAC/RIC (n=41), the cumulative incidence of grade II-IV acute GVHD at day 100 was 31%, grade II-IV acute GVHD at one year was 28%, and chronic GVHD at one year was 36%. This institutional analysis shows that the combination of MMF and tacrolimus yields acceptable outcomes for the prevention of acute and chronic GVHD.
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Affiliation(s)
- Hamza Hashmi
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, H. Lee Moffitt Cancer and Research Center, Tampa, USA
| | - Shruti Bhandari
- Division of Medical Oncology and Hematology, University of Louisville, Louisville, USA
| | - Jugraj Dhanoa
- Internal Medicine, University of Louisville, School of Medicine, Louisville, USA
| | - Xiaoyong Wu
- Bioinformatics and Biostatistics, University of Louisville, School of Public Health and Information Science, Louisville, USA
| | - Shesh Rai
- Bioinformatics and Biostatistics, University of Louisville, School of Public Health and Information Science, Louisville, USA
| | - Lindsay Figg
- Division of Clinical Oncology Pharmacy, University of Louisville Hospital, Louisville, USA
| | - Timothy Baize
- Division of Clinical Oncology Pharmacy, University of Louisville Hospital, Louisville, USA
| | - Maxwell Krem
- Division of Hematology and Blood and Marrow Transplant, University of Kentucky, Lexington, USA
| | - Mohamed Hegazi
- Division of Blood and Marrow Transplant, University of Louisville, Louisville, USA
| | - Robert Emmons
- Division of Blood and Marrow Transplant, University of Louisville, Louisville, USA
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50
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A Phase 3, Single-Arm, Prospective Study of Remestemcel-L, Ex Vivo Culture-Expanded Adult Human Mesenchymal Stromal Cells for the Treatment of Pediatric Patients Who Failed to Respond to Steroid Treatment for Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2020; 26:845-854. [PMID: 32018062 PMCID: PMC8322819 DOI: 10.1016/j.bbmt.2020.01.018] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/17/2020] [Accepted: 01/26/2020] [Indexed: 12/17/2022]
Abstract
Steroid-refractory acute graft-versus-host disease (SR-aGVHD) following hematopoietic cell transplantation (HSCT) is associated with poor clinical outcomes. Currently, there are no safe and effective therapies approved for use in the pediatric population under the age of 12 years. Accordingly, there is an urgent need for new treatments that are safe, well tolerated, and effective in managing this debilitating and potentially fatal complication of HSCT. In early phase clinical trials, mesenchymal stromal cells (MSCs) have demonstrated efficacy in the treatment of acute GVHD (aGVHD) in pediatric patients. We now report the results of a phase 3, prospective, single-arm, multicenter study (NCT02336230) in 54 children with primary SR-aGVHD who were naive to other immunosuppressant therapies for aGVHD treated with MSC product (remestemcel-L) dosed at 2 × 106 cells/kg twice weekly for 4 weeks. Remestemcel-L therapy significantly improved day 28 overall response rate (OR) compared with the prespecified control OR value of 45% (70.4% versus 45%, P = .0003). The statistically significant OR (70.4%) was sustained through day 100, including an increase in complete response from 29.6% at day 28 to 44.4% at day 100. Overall survival was 74.1% at day 100 and 68.5% at day 180. Overall response in all participants at day 28 was highly predictive of improved survival through 180 days, and survival was significantly greater in day 28 responders compared with nonresponders through day 100 (86.8% versus 47.1% for responders and nonresponders, respectively, P = .0001) and through day 180 (78.9% versus 43.8%, P = .003). Remestemcel-L was well tolerated with no identified infusion-related toxicities or other safety concerns. This study provides robust, prospective evidence of the safety, tolerability, and efficacy of remestemcel-L as first-line therapy after initial steroid failure in pediatric SR-aGVHD.
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