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Akahoshi Y, Spyrou N, Weber D, Aguayo-Hiraldo P, Ayuk F, Chanswangphuwana C, Choe HK, Eder M, Etra AM, Grupp SA, Hexner EO, Hogan WJ, Kitko CL, Kraus S, Al Malki MM, Merli P, Qayed M, Reshef R, Schechter T, Ullrich E, Vasova I, Wölfl M, Zeiser R, Baez J, Beheshti R, Eng G, Gleich S, Katsivelos N, Kowalyk S, Morales G, Young R, Chen YB, Nakamura R, Levine JE, Ferrara JLM. Novel MAGIC composite scores using both clinical symptoms and biomarkers best predict treatment outcomes of acute GVHD. Blood 2024; 144:1010-1021. [PMID: 38968143 DOI: 10.1182/blood.2024025106] [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: 04/26/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/07/2024] Open
Abstract
ABSTRACT Acute graft-versus-host disease (GVHD) grading systems that use only clinical symptoms at treatment initiation such as the Minnesota risk identify standard and high-risk categories but lack a low-risk category suitable to minimize immunosuppressive strategies. We developed a new grading system that includes a low-risk stratum based on clinical symptoms alone and determined whether the incorporation of biomarkers would improve the model's prognostic accuracy. We randomly divided 1863 patients in the Mount Sinai Acute GVHD International Consortium (MAGIC) who were treated for GVHD into training and validation cohorts. Patients in the training cohort were divided into 14 groups based on similarity of clinical symptoms and similar nonrelapse mortality (NRM); we used a classification and regression tree (CART) algorithm to create three Manhattan risk groups that produced a significantly higher area under the receiver operating characteristic curve (AUC) for 6-month NRM than the Minnesota risk classification (0.69 vs 0.64, P = .009) in the validation cohort. We integrated serum GVHD biomarker scores with Manhattan risk using patients with available serum samples and again used a CART algorithm to establish 3 MAGIC composite scores that significantly improved prediction of NRM compared to Manhattan risk (AUC, 0.76 vs 0.70, P = .010). Each increase in MAGIC composite score also corresponded to a significant decrease in day 28 treatment response (80% vs 63% vs 30%, P < .001). We conclude that the MAGIC composite score more accurately predicts response to therapy and long-term outcomes than systems based on clinical symptoms alone and may help guide clinical decisions and trial design.
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Affiliation(s)
- Yu Akahoshi
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nikolaos Spyrou
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Daniela Weber
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Paibel Aguayo-Hiraldo
- Division of Bone Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | - Francis Ayuk
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chantiya Chanswangphuwana
- Division of Hematology and Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Hannah K Choe
- Division of Hematology, Blood and Marrow Transplant Program, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Aaron M Etra
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Stephan A Grupp
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth O Hexner
- Department of Medicine and Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Carrie L Kitko
- Pediatric Hematology/Oncology Division, Vanderbilt University Medical Center, Nashville, TN
| | - Sabrina Kraus
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | | | - Pietro Merli
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Muna Qayed
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Ran Reshef
- Division of Hematology/Oncology and Columbia Center for Translational Immunology, Columbia University Irving Medical Center, New York, NY
| | - Tal Schechter
- Division of Hematology/Oncology/BMT, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evelyn Ullrich
- Department of Pediatrics, Experimental Immunology and Cell Therapy, Goethe University Frankfurt, Frankfurt, Germany
| | - Ingrid Vasova
- Department of Internal Medicine 5, Hematology and Oncology, Friedrich-Alexander-Universität Erlangen-Nürnberg and University Hospital Erlangen, Erlangen, Germany
| | - Matthias Wölfl
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Janna Baez
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rahnuma Beheshti
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gilbert Eng
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sigrun Gleich
- Department of Hematology and Oncology, Internal Medicine III, University of Regensburg, Regensburg, Germany
| | - Nikolaos Katsivelos
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Steven Kowalyk
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - George Morales
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachel Young
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA
| | | | - John E Levine
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - James L M Ferrara
- Division of Hematology/Medical Oncology, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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2
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Marcoux CM, Alousi AM, Im J, Hill LC, Smallbone P, Popat U, Hosing C, Kebriaei P, Olson A, Mehta R, Chen G, Qazilbash M, Shpall E, Champlin RC, Saliba RM. Gastrointestinal involvement refines prognosis in minnesota standard risk acute graft-vs.-host disease. Bone Marrow Transplant 2024:10.1038/s41409-024-02393-1. [PMID: 39187601 DOI: 10.1038/s41409-024-02393-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 07/02/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024]
Abstract
Minnesota acute graft versus host disease (AGVHD) risk score is a validated tool to stratify newly-diagnosed patients into standard-risk (SR) and high-risk (HR) groups with ~85% having SR AGVHD. We aimed to identify factors for further risk-stratification within Minnesota SR patients. A single-center, retrospective analysis of consecutive patients between 1/2010 and 12/2014 was performed. Patients who developed AGVHD within 100 days and treated with systemic corticosteroids were included (N = 416), 356 (86%) of which were Minnesota SR and 60 (14%) had HR AGVHD. Isolated upper gastrointestinal (GI) AGVHD patients had significantly better day 28 and 56 CR/PR rates (90% vs. 72%, p = 0.004) and (83% vs 66%, p = 0.01), respectively, and lower 1-year non-relapse mortality (NRM; 10% vs. 22%; HR 0.4, p = 0.03). Lower GI AGVHD had less favorable outcomes with 1-year NRM of 40% (HR 2.1, p = 0.001), although CR/PR rates were not statistically different. In multivariate analysis, lower GI involvement (HR 2.6, p < 0.001), age ≥ 50 (HR 2.9, p < 0.001) and HCT-CI > 3 (HR 2.1, p = 0.002) predicted for 1-year NRM. Heterogeneity within Minnesota SR patients requires consideration in clinical trials, as distinct outcomes are observed in those with isolated upper GI and lower GI AGVHD, highlighting the importance of stratification in clinical trial design.
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Affiliation(s)
- Curtis M Marcoux
- Division of Hematology, Dalhousie University, Halifax, NS, Canada
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Jin Im
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laquisa C Hill
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Portia Smallbone
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Chitra Hosing
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Partow Kebriaei
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Amanda Olson
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Rohtesh Mehta
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - George Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard C Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chen YB, Mohty M, Zeiser R, Teshima T, Jamy O, Maertens J, Purtill D, Chen J, Cao H, Rossiter G, Jansson J, Fløisand Y. Vedolizumab for the prevention of intestinal acute GVHD after allogeneic hematopoietic stem cell transplantation: a randomized phase 3 trial. Nat Med 2024; 30:2277-2287. [PMID: 38844797 PMCID: PMC11333288 DOI: 10.1038/s41591-024-03016-4] [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: 12/18/2023] [Accepted: 04/23/2024] [Indexed: 08/21/2024]
Abstract
Acute graft-versus-host disease (aGVHD) of the lower gastrointestinal (GI) tract is a major cause of morbidity and mortality in patients receiving allogeneic hematopoietic stem cell transplantation (allo-HSCT). Vedolizumab is a gut-selective anti-α4β7 integrin monoclonal antibody that reduces gut inflammation by inhibiting migration of GI-homing T lymphocytes. The efficacy and safety of vedolizumab added to standard GVHD prophylaxis (calcineurin inhibitor plus methotrexate/mycophenolate mofetil) was evaluated for prevention of lower-GI aGVHD after unrelated donor allo-HSCT in a randomized, double-blind, placebo-controlled phase 3 trial. Enrollment closed early during the COVID-19 pandemic with 343 patients randomized (n = 174 vedolizumab, n = 169 placebo), and 333 received ≥1 intravenous dose of 300 mg vedolizumab (n = 168) or placebo (n = 165) and underwent allo-HSCT. The primary end point was met; Kaplan-Meier (95% confidence interval) estimated rates of lower-GI aGVHD-free survival by day +180 after allo-HSCT were 85.5% (79.2-90.1) with vedolizumab versus 70.9% (63.2-77.2) with placebo (hazard ratio, 0.45; 95% confidence interval, 0.27-0.73; P < 0.001). For the 5 key secondary efficacy end points analyzed by day +180 after allo-HSCT, rates of lower-GI aGVHD-free and relapse-free survival and grade C-D aGVHD-free survival were significantly higher with vedolizumab versus placebo. No significant treatment differences were found for the other key secondary end points of non-relapse mortality, overall survival and grade B-D aGVHD-free survival, respectively. Incidence of treatment-related serious adverse events analyzed in patients receiving ≥1 dose of study treatment (n = 334) was 6.5% (n = 11 of 169) vedolizumab versus 8.5% (n = 14 of 165) placebo. When added to standard calcineurin inhibitor-based GVHD prevention, lower-GI aGVHD-free survival was significantly higher with vedolizumab versus placebo. ClinicalTrials.gov identifier: NCT03657160 .
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Affiliation(s)
- Yi-Bin Chen
- Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA, USA.
| | - Mohamad Mohty
- Hematology Department, AP-HP, Hôpital Saint-Antoine, Sorbonne Université and INSERM UMRs 938, Paris, France
| | - Robert Zeiser
- Department of Medicine I - Medical Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Omer Jamy
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Johan Maertens
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Duncan Purtill
- Department of Haematology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | | | | | | | | | - Yngvar Fløisand
- Centre for Cancer Cell Reprogramming, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Feng Q, Xu F, Guan K, Li T, Sheng J, Zhong W, Wu H, Li B, Peng P. Diagnostic prediction of gastrointestinal graft-versus-host disease based on a clinical- CT- signs nomogram model. Insights Imaging 2024; 15:84. [PMID: 38517664 PMCID: PMC10959888 DOI: 10.1186/s13244-024-01654-3] [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: 09/19/2023] [Accepted: 02/10/2024] [Indexed: 03/24/2024] Open
Abstract
OBJECTIVE Gastrointestinal graft-versus-host disease (GI-GVHD) is one of the complications that can easily occur after hematopoietic stem cell transplantation (HSCT). Timely diagnosis and treatment are pivotal factors that greatly influence the prognosis of patients. However, the current diagnostic method lacks adequate non-invasive diagnostic tools. METHODS A total of 190 patients who suspected GI-GVHD were retrospectively included and divided into training set (n = 114) and testing set (n = 76) according to their discharge time. Least absolute shrinkage and selection operator (LASSO) regression was used to screen for clinically independent predictors. Based on the logistic regression results, both computed tomography (CT) signs and clinically independent predictors were integrated in order to build the nomogram, while the testing set was verified independently. The receiver operating characteristic (ROC), area under the curve (AUC), decision curve, and clinical impact curve were used to measure the accuracy of prediction, clinical net benefit, and consistency of diagnostic factors. RESULTS Four key factors, including II-IV acute graft-versus-host disease (aGVHD), the circular target sign, multifocal intestinal inflammation, and an increased in total bilirubin, were identified. The combined model, which was constructed from CT signs and clinical factors, showed higher predictive performances. The AUC, sensitivity, and specificity of the training set were 0.867, 0.787, and 0.811, respectively. Decision curve analysis (DCA), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) showed that the developed model exhibited a better prediction accuracy than the others. CONCLUSIONS This combined model facilitates timely diagnosis and treatment and subsequently improves survival and overall outcomes in patients with GI-GVHD. CRITICAL RELEVANCE STATEMENT GI-GVHD is one of the complications that can easily occur after HSCT. However, the current diagnostic approach lacks adequate non-invasive diagnostic methods. This non-invasive combined model facilitates timely treatment and subsequently improves patients with GI-GVHD survival and overall outcomes. KEY POINTS • There is currently lacking of non-invasive diagnostic methods for GI-GVHD. • Four clinical CT signs are the independent predictors for GI-GVHD. • Association between the CT signs with clinical factors may improve the diagnostic performance of GI-GVHD.
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Affiliation(s)
- Qing Feng
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Shuangyong Road, Nanning, 530021, Guangxi Province, China
- Department of Radiology, Liuzhou Workers' Hospital, Heping Road, Liuzhou, 545005, Guangxi Province, China
| | - Fengming Xu
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Shuangyong Road, Nanning, 530021, Guangxi Province, China
| | - Kaiming Guan
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Shuangyong Road, Nanning, 530021, Guangxi Province, China
| | - Tao Li
- Department of Radiology, Liuzhou Workers' Hospital, Heping Road, Liuzhou, 545005, Guangxi Province, China
| | - Jing Sheng
- Department of Radiology, Liuzhou People's Hospital, Guangchang Road, Liuzhou, 545000, Guangxi Province, China
| | - Wei Zhong
- Department of Radiology, Liuzhou Workers' Hospital, Heping Road, Liuzhou, 545005, Guangxi Province, China
| | - Haohua Wu
- Department of Radiology, Liuzhou Workers' Hospital, Heping Road, Liuzhou, 545005, Guangxi Province, China
| | - Bing Li
- Department of Radiology, Liuzhou Workers' Hospital, Heping Road, Liuzhou, 545005, Guangxi Province, China
| | - Peng Peng
- Department of Radiology, The First Affiliated Hospital of Guangxi Medical University, Shuangyong Road, Nanning, 530021, Guangxi Province, China.
- NHC Key Laboratory of Thalassemia Medicine, Nanning, 530021, Guangxi Province, China.
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Scott AP, Henden A, Kennedy GA, Tey SK. PET assessment of acute gastrointestinal graft versus host disease. Bone Marrow Transplant 2023; 58:973-979. [PMID: 37537245 PMCID: PMC10471499 DOI: 10.1038/s41409-023-02038-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 08/05/2023]
Abstract
Acute gastrointestinal graft versus host disease (GI-GVHD) is a common complication following allogeneic haematopoietic cell transplantation (HCT), and is characterised by severe morbidity, frequent treatment-refractoriness, and high mortality. Early, accurate identification of GI-GVHD could allow for therapeutic interventions to ameliorate its severity, improve response rates and survival; however, standard endoscopic biopsy is inadequately informative in terms of diagnostic sensitivity or outcome prediction. In an era where rapid technological and laboratory advances have dramatically expanded our understanding of GI-GVHD biology and potential therapeutic targets, there is substantial scope for novel investigations that can precisely guide GI-GVHD management. In particular, the combination of tissue-based biomarker assessment (plasma cytokines, faecal microbiome) and molecular imaging by positron emission tomography (PET) offers the potential for non-invasive, real-time in vivo assessment of donor:recipient immune activity within the GI tract for GI-GVHD prediction or diagnosis. In this article, we review the evidence regarding GI-GVHD diagnosis, and examine the potential roles and translational opportunities posed by these novel diagnostic tools, with a focus on the evolving role of PET.
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Affiliation(s)
- Ashleigh P Scott
- Department of Haematology and Bone Marrow Transplant, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Andrea Henden
- Department of Haematology and Bone Marrow Transplant, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Glen A Kennedy
- Department of Haematology and Bone Marrow Transplant, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Siok-Keen Tey
- Department of Haematology and Bone Marrow Transplant, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
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Kurya AU, Aliyu U, Tudu AI, Usman A, Yusuf M, Gupta S, Ali A, Gulfishan M, Singh SK, Hussain I, Abubakar MG. Graft-versus-host disease: Therapeutic prospects of improving the long-term post-transplant outcomes. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Retinoic acid-responsive CD8 effector T cells are selectively increased in IL-23-rich tissue in gastrointestinal GVHD. Blood 2021; 137:702-717. [PMID: 32905596 DOI: 10.1182/blood.2020005170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/25/2020] [Indexed: 01/12/2023] Open
Abstract
Gastrointestinal (GI) graft-versus-host disease (GVHD) is a major barrier in allogeneic hematopoietic stem cell transplantation (allo-HSCT). The metabolite retinoic acid (RA) potentiates GI-GVHD in mice via alloreactive T cells expressing the RA receptor-α (RARα), but the role of RA-responsive cells in human GI-GVHD remains undefined. Therefore, we used conventional and novel sequential immunostaining and flow cytometry to scrutinize RA-responsive T cells in tissues and blood of patients who had received allo-HSCT and to characterize the impact of RA on human T-cell alloresponses. Expression of RARα by human mononuclear cells was increased after exposure to RA. RARαhi mononuclear cells were increased in GI-GVHD tissue, contained more cellular RA-binding proteins, localized with tissue damage, and correlated with GVHD severity and mortality. By using a targeted candidate protein approach, we predicted the phenotype of RA-responsive T cells in the context of increased microenvironmental interleukin-23 (IL-23). Sequential immunostaining confirmed the presence of a population of RARαhi CD8 T cells with the predicted phenotype that coexpressed the effector T-cell transcription factor T-bet and the IL-23-specific receptor (IL-23R). These cells were increased in GI- but not skin-GVHD tissues and were also selectively expanded in the blood of patients with GI-GVHD. Finally, functional approaches demonstrated that RA predominantly increased alloreactive GI-tropic RARαhi CD8 effector T cells, including cells with the phenotype identified in vivo. IL-23-rich conditions potentiated this effect by selectively increasing β7 integrin expression on CD8 effector T cells and reducing CD4 T cells with a regulatory cell phenotype. In summary, we have identified a population of RA-responsive effector T cells with a distinctive phenotype that is selectively expanded in human GI-GVHD and that represents a potential new therapeutic target.
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Klasen JM, Peterson CJ, Fourie LL, Boldanova T, Terracciano LM, Holbro A, Kollmar O. Small crystals with severe consequences. J Surg Case Rep 2021; 2021:rjab135. [PMID: 33927869 PMCID: PMC8068420 DOI: 10.1093/jscr/rjab135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/17/2021] [Indexed: 12/02/2022] Open
Abstract
We present the case of a 23-year-old patient who developed a severe gastric ischemia after the ingestion of a single dose of sodium polystyrene sulfonate (SPS) orally. Emergency surgery confirmed extensive full thickness gastric necrosis, prompting a total gastrectomy. Histopathology showed kayexalate crystals in the gastric wall, suggesting SPS-related ischemic gastritis. After radical resection of the affected stomach, this young patient was able to fully recover. Although effective, the widespread use of SPS to treat hyperpotassemia remains a debated topic because of rare but serious adverse events like the forming of kayexalate crystal residues in the gastrointestinal tract. These crystal residues are mostly found in the large intestine and can lead to ulceration and necrosis. Physicians need to be aware of this rare but potentially devastating adverse effect of SPS ingestion.
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Affiliation(s)
- Jennifer M Klasen
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Caspar J Peterson
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Lana L Fourie
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Tuyana Boldanova
- Clarunis, Department of Gastroenterology and Hepatology, University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Luigi M Terracciano
- Molecular Pathology Division, Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - Andreas Holbro
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Otto Kollmar
- Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
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9
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Frairia C, Nicolosi M, Shapiro J, Kim J, Betts BC, Fernandez HF, Locke FL, Mishra A, Nishihori T, Ochoa-Bayona JL, Perez L, Pidala J, Anasetti C. Sole Upfront Therapy with Beclomethasone and Budesonide for Upper Gastrointestinal Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2020; 26:1303-1311. [PMID: 32361010 DOI: 10.1016/j.bbmt.2020.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/25/2020] [Accepted: 04/19/2020] [Indexed: 11/28/2022]
Abstract
Systemic glucocorticoids remain the standard treatment for gastrointestinal (GI) acute graft-versus-host disease (aGVHD) despite their toxicity and incomplete efficacy. Controlled trials have tested poorly absorbable steroids as adjuncts with systemic glucocorticoids, but only small case series have reported treatment with poorly absorbed beclomethasone dipropionate (BDP) and budesonide (BUD) alone. Our team has adopted the practice of administering BDP or BDP+BUD without systemic glucocorticoids as first-line therapy for isolated upper GI (UGI) aGVHD. We report results in 76 patients treated with BDP alone and in 81 patients treated with BDP+BUD, with allocation by physician choice. Almost all patients received peripheral blood stem cells (92%) from a fully HLA-matched related or unrelated donor (80%) after myeloablative conditioning (76%) for acute leukemia (49%), myelodysplastic syndrome (17%), non-Hodgkin lymphoma (14%), or another hematopoietic disorders (20%). After 28 days of treatment with BDP, 46% of the patients had a complete response (CR) and 10% had a partial response (PR); after 200 days, 61 (80%) patients were alive, 34% maintained a CR, and 3% maintained a PR, whereas 53% required additional immunosuppression (IS). After 28 days of treatment with BDP+BUD, 67% had a CR and 10% a PR; after 200 days, 74 (91%) patients were alive, 46% maintained a CR, and 2% maintained a PR, whereas 43% required additional IS. Among the entire cohort of 157 patients, 66 (42%) were treated successfully without systemic glucocorticoids. This study reports the efficacy of poorly absorbable steroids alone for patients with isolated UGI aGVHD. Prospective trials should test for the potential advantages of BDP and BUD use over systemic glucocorticoids.
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Affiliation(s)
- Chiara Frairia
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida.
| | - Maura Nicolosi
- Department of Hematology, University-Hospital Città della Salute e della Scienza, Torino, Italy
| | - Jamie Shapiro
- Clinical Pharmacy, Moffitt Cancer Center, Tampa, Florida
| | - Jongphil Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Brian C Betts
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Clinical Pharmacy, Moffitt Cancer Center, Tampa, Florida; Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Hugo F Fernandez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Frederick L Locke
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Asmita Mishra
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Jose Leonel Ochoa-Bayona
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Lia Perez
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Joseph Pidala
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida
| | - Claudio Anasetti
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida; Department of Oncological Sciences, University of South Florida, Tampa Florida.
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