Occurrence Of aGVHD Research Articles

Cytomegalovirus DNA load monitoring in stool specimens for anticipating the occurrence of intestinal acute graft-versus-host disease following allogeneic hematopoietic stem cell transplantation: Is it of any value?

Data have been published suggesting a bidirectional interaction between cytomegalovirus (CMV) infection and acute graft-versus-host disease (aGvHD) in allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients. Here, we hypothesized that prospective CMV DNA monitoring in stool specimens may be useful for predicting subsequent occurrence of intestinal aGvHD (IaGvHD). This two-center study enrolled 121 consecutive adult patients undergoing any modality of allo-HSCT. A total of 1,009 stool specimens were collected (a median of 7 specimens/patient; range, 1-18). CMV DNA monitoring in stools and plasma was performed using real-time PCR assays. CMV DNA was detected in stools in 20 patients (cumulative incidence, 16.9%; 95% CI, 6.3%-31.8%). Median CMV DNA level in stool specimens was 1,258IU/0.1g (range, 210-4,087IU/0.1g). All these patients and their donors were CMV seropositive, and 16 of the 20 patients also had CMV DNAemia, while 4 patients had CMV DNA detected in stools without CMV DNAemia. No correlation was found between CMV DNA loads in plasma and stools (P=.40). Prior CMV DNAemia, aGvHD, or IaGvHD were not associated with presence of CMV DNA in feces. IaGvHD was present in 30 patients, in 5 of whom CMV DNA was detected in stools. Neither detection of CMV DNA in feces nor in plasma was associated with subsequent IaGvHD (OR, 0.67; 95% CI, 0.18-2.52; P=.55 and OR, 0.86; 95% CI, 0.38-1.96; P=.71, respectively). No patient in this cohort had CMV end-organ disease within the study period. Our study failed to provide evidence pointing to a reciprocal interaction between GI CMV infection and IaGvHD. CMV DNA monitoring in stools seems of no value to anticipate occurrence of IaGvHD.

The stability of initial tacrolimus concentration following allogeneic hematopoietic stem cell transplantation reduces the risk of acute GVHD.

Early tacrolimus (TAC) concentrations correlate with the risk of acute graft-versus-host disease (aGVHD); however, whether the variability of early TAC concentrations after allo-HSCT governs the occurrence of aGVHD remains unknown. Here, we evaluate the correlation between the intrapatient variability (IPV) of initial TAC concentrations and the development of aGVHD. We retrospectively assessed 202 patients who underwent allo-HSCT and received standard GVHD prophylaxis by continuous intravenous (iv) infusion of TAC and iv methotrexate. IPV was calculated by using the % coefficient of variation in the initial 4weeks. With median follow-up duration of 20.7months, 24 patients were diagnosed with grades II-IV aGVHD. Overall survival (OS) and relapse at 12months after allo-HSCT were 70.6% (95% confidence interval [CI], 63.7%-76.4%) and 18.9% (95% CI, 13.0%-24.4%), respectively. When IPV was categorized into two groups (high: ≥9.5%; low: <9.5%), the cumulative incidence of grades II-IV aGVHD was greater in the IPV-high group at week 3 (odds ratio: 4.15; 95% CI, 1.37%-12.6%, P=.01). No significant differences were observed in OS and relapse between the two groups. We concluded that adjusting early TAC concentration stable may reduce aGVHD after allo-HSCT without affecting the relapse rate.

Monocyte subsets in bone marrow grafts may contribute to a low incidence of acute graft-vs-host disease for young donors.

Young donors are associated with a lower cumulative incidence of acute graft‐vs‐host disease (aGVHD) after allogenic haematopoietic stem cell transplantation (allo‐HSCT) than old donors. Although grafts are harvested from healthy donors, it is unclear whether donor age is associated with aGVHD occurrence owing to its effect on cell compositions in grafts. Moreover, the differences in monocyte subsets in grafts between young and old donors and the association between monocyte subsets in bone marrow (BM) grafts and aGVHD remain to be elucidated. In the current study, non‐classical monocytes and the CD4+/CD8+ T cell ratio were remarkably decreased in BM grafts in donors <30 years old. Multivariate analysis further revealed that the level of non‐classical monocytes in BM grafts (≥0.31 × 106/kg) was an independent risk factor for the occurrence of II‐IV aGVHD. In summary, our data indicate that non‐classical monocytes in BM grafts may help identify patients at high risk for aGVHD after allo‐HSCT. Although further validation is required, our results suggest that the low level of non‐classical monocytes and a low ratio of CD4+/CD8+ T cell in BM grafts may be correlated with the lower incidence of aGVHD in young donors.

Diagnosis and treatment of acute graft-versus-host disease after liver transplantation: A report of 11cases

Objective: This study aims to summarize a clinical experience on the diagnosis and treatment of acute graft-versus-host disease (aGVHD) after liver transplantation.Methods: Between April 2005 and August 2016, 11 recipients who underwent OLT developed aGVHD with clinical symptoms of fever, rash, diarrhea and pancytopenia. T lymphocyte chimerism was detected though STR-PCR. These patients were treated with immunosuppressant adjustment, methylprednisolone, basiliximab, etc. All the results were recorded and summarized.Results: We demonstrated the diagnostic criteria of aGVHD based on our experiences: 1 aGVHD occurred from two weeks to two months after the liver transplantation. Fever, rash, digestive tract symptoms and bone marrow suppression were the four symptoms that appeared in any orde, All the percentages of donor T lymphocytes of aGVHD patients were more than 10%. All 11 recipients underwent treatments including immunosuppressant adjustment, glucocorticoids, IVIG and organ function support. Among these recipients, two survived due to successful treatment, while nine recipients died due to infection and cerebral and digestive tract hemorrhage. It is noteworthy that the occurrence of aGVHD was related to the dose of immunosuppressive agents, and we suggest the concept of “aGVHD induced by immunosuppression”.Conclusions: The diagnostic criteria of aGVHD is mainly based on time, clinical symptoms, T-lymphocyte chimerism and histopathology. The concept of “aGVHD induced by immunosuppression” provides important guidance in immunosuppressant management, control, and prevention of infection. Support treatment is very important in the treatment of aGVHD.

Individual HLA alleles and risk of graft-versus-host disease after haematopoietic stem cell transplantation from HLA-identical siblings

Graft-versus-host disease (GVHD) in its acute (aGVHD) and chronic (cGVHD) form remains one of the most serious complications of allogeneic haematopoietic stem cell transplantation (allo-HSCT). There are several risk factors known to be associated with GVHD development. Some reports suggest that certain human leukocyte antigen (HLA) variants may influence the incidence of GVHD. The aim of our study was to analyse possible association between individual HLA alleles and the occurrence of aGVHD and cGVHD in patients following allo-HSCT from HLA-identical sibling donors. We have retrospectively reviewed medical records of 96 patients who received a transplant in the years 1994–2008. Cumulative incidence of acute GVHD was 31.3% and that of chronic GVHD was 26.0%. Recipients carrying the HLA-A*01, -DRB1*03 and -DQB1*03 alleles showed a statistically significantly lower incidence of aGVHD. Furthermore, the HLA-DQB1*06 allele was associated with a higher incidence of cGVHD. Each of these alleles was confirmed by logistic regression analysis as an independent factor with impact on GVHD development. Our results support findings of authors showing an association between certain HLA variants and GVHD appearance. However, other authors assume that there is no convincing evidence for such an association. Therefore, when taking into account limitations of our study design and the significant inconsistency in the results of the previous reports, a careful approach in judgement is required. To conclude, in our view, the prognostic value of individual HLA variants for GVHD development in a setting of HLA-identical allo-HSCT does not seem to be of great clinical relevance.

Low cyclosporine concentrations in children and time to acute graft versus host disease

BackgroundAchievement of target blood concentrations of cyclosporine (CsA) early after transplantation is known to be highly effective for reducing the incidence of acute graft versus host disease (aGVHD). However, no research has been conducted for predicting aGVHD occurrence with low CsA concentrations at different time periods. The objective of this study was to investigate the risk of aGVHD according to low CsA concentrations at lag days in children with allogenic hematopoietic stem cell transplantation (HSCT).MethodsThe records of 61 consecutive children who underwent allogeneic HSCT and received CsA as prophylaxis against aGVHD between May 2012 and March 2015 were retrospectively evaluated. The main outcome was any association between low CsA concentrations at lag days and aGVHD occurrence, which was examined for the first month after transplantation. Mean CsA concentrations at three lag periods were calculated: lag days 0–6, 7–13, and 14–20 before aGVHD occurrence.ResultsPatients whose mean CsA concentrations at lag days 0–6 did not reach the initial target concentration had 11.0-fold (95% confidence interval [CI]: 2.3–51.9) greater incidence of aGVHD. In addition, the AORs of low CsA concentrations at lag days 7–13 and 14–20 for developing aGVHD were 108.2 (95% CI: 7.7–1515.5) and 12.1 (95% CI: 1.1–138.1), respectively.ConclusionsAfter low CsA concentrations are detected, careful attention needs to be paid to prevent aGVHD.

Viral reactivations following hematopoietic stem cell transplantation in pediatric patients – A single center 11-year analysis

Viral reactivation occurs frequently in the context of immunodeficiency and immunosuppression after allogeneic hematopoietic stem cell transplantation (allo-HSCT) and can cause severe complications. The aim of this single-center retrospective analysis was to characterize viral infections in the first year after HSCT, to investigate risk factors and to study the impact of viral infections on transplantation outcome. This will facilitate the identification of at-risk patients and the development of new preventive strategies. 107 pediatric allo-HSCT from January 2005 through December 2015 were analyzed for infections with Epstein-Barr virus (EBV), cytomegalovirus (CMV), human herpesvirus 6 (HHV-6), adenovirus (ADV), herpes simplex virus (HSV) and varicella zoster virus (VZV). Viral infections were detected after 68.2% of transplantations. The viruses most commonly encountered were HHV-6 (36/107) and EBV (30/107). Severe viral disease was rare (7/107) and none of the patients died as result of viral reactivation. Important risk factors for viral infections were higher age at HSCT, donor type and occurrence of acute graft-versus-host disease (aGvHD). Especially for EBV, transplant from an unrelated donor and in-vivo T-cell depletion (TCD) had a significant effect on infection rates, whereas for CMV the strongest effect was seen by donor and recipient serostatus with recipient seropositivity most predictive for reactivation. The occurrence of severe aGvHD was associated with EBV and ADV infections. For HSV, the recipient serostatus was identified as prognostic factor for HSV infections, while we found higher age at time of HSCT as risk factor for VZV infections. The overall survival of patients with or without viral infections did not differ significantly. Interestingly, when looking at the 85 patients in our cohort who had received an HSCT for a malignant disease, a tendency towards lower relapse rates was seen in patients affected by viral infections (HR 0.51, 95% CI 0.25 – 1.06, p = 0.072). Viral reactivations are common after pediatric allo-HSCT, though severe complications were rare in our collective. Determining risk factors for viral reactivations may help to identify patients in need of intensified monitoring and to individualize preventive strategies.

Race/Ethnicity and Socioeconomic Status in Pediatric Allogeneic Hematopoietic Cell Transplantation for Non-Malignant Conditions

<h3>Introduction</h3> Survival disparities by race/ethnicity and socioeconomic status (SES) have been observed in a wide range of pediatric treatment settings. Few studies have examined the effects of ethnicity and SES in pediatric allogeneic hematopoietic cell transplantation (alloHCT). <h3>Objectives</h3> We explored whether survival differed by ethnicity or SES in children receiving alloHCT for non-malignant conditions at a single institution serving a diverse patient population. <h3>Methods</h3> The Kaplan-Meier method was used to estimate overall survival (OS) with the logrank test for between-group comparisons. Cox proportional hazards models were used for adjusted analyses of OS. <h3>Results</h3> Of 133 subjects from <1-21yrs, 19% were non-Hispanic white (NHW), 34% were non-Hispanic black (NHB), 40% were Hispanic, and 7% were Asian. 67% had public insurance and 47% of patients lived in neighborhoods where median family income was ≤$44,100/yr. Indications for alloHCT were hemoglobinopathy (56%), bone marrow failure (22%), and other (22%). Mean follow up was 6.5yrs (SD=4.4) and did not differ by ethnicity. Overall survival for the entire cohort was 88% (SE=3.3) at 5.8yrs. On univariable analysis, hazard of mortality did not differ by race/ethnicity or insurance, and hazard of mortality was lower in patients from lower income neighborhoods (Table). In multivariable analysis, only aGVHD was associated with inferior OS (HR 6.7, CI95% 2.3-19.5 p<0.001). <h3>Conclusion</h3> Our findings suggest that in patients undergoing alloHCT for non-malignant conditions, treatment at a tertiary care center with a multidisciplinary approach may mitigate the health disparities seen in other treatment settings. Future research should include larger multicenter studies investigating the complex interrelationships among race/ethnicity, SES, and clinical outcomes in this understudied patient population. Occurrence of aGVHD was the only factor associated with inferior OS, emphasizing a need for better prevention and treatment strategies in children with non-malignant diseases.

The effect of graft-versus-host disease on outcomes after allogeneic stem cell transplantation for refractory lymphoblastic lymphoma in children and young adults.

Patients with relapsed or refractory lymphoblastic lymphoma (LBL) have a poor prognosis. The efficacy of allogeneic blood stem cell transplantation for treatment of this disease remains unclear in terms of transplantation-related toxicity. Acute and chronic graft-versus-host diseases (GVHD) are both harmful to patients after allogeneic transplantation, but may have some positive effects through a substitute graft-versus-lymphoma effect. To investigate the effect of GVHD on the survival of patients with refractory LBL, we retrospectively studied the outcomes of 213 patients with LBL who underwent first allogeneic stem cell transplantation before the age of 18 years, between 1990 and 2015 in Japan. The five-year overall survival (OS) and event-free survival rates after stem cell transplantation were 50.3% (95% confidence interval [CI], 43.2-56.9) and 47.8% (95% CI, 40.8-54.4), respectively. In univariate landmark analyses, the probability of OS was significantly better in patients with aGVHD than in those without (P=0.002, five-year OS 58.1% vs 39.0%). The probability of OS was also better in patients with cGVHD than in those without (P=0.036, five-year OS 72.2% vs 54.7%). Multivariate analysis demonstrated that only aGVHD was associated with better OS (hazard ratio, 0.63; 95% CI, 0.42-0.94, P=0.024). Progression and recurrence statuses at SCT were associated with poor prognosis. The patients with grade II aGVHD showed the best prognosis (five-year OS: 65.6%). Our results suggest that the occurrence of aGVHD may be associated with better outcomes in patients with relapsed/refractory LBL who undergo allogeneic transplantation.

Is There Any Impact of Uric Acid Levels during the Peri-Transplant Period on Acute Graft Vs. Host Disease Incidence and Allotransplant Outcome?

Background: Damage associated molecular patterns (DAMPs) are considered important contributors to acute Graft vs Host Disease (aGvHD) pathogenesis. Uric acid (UA), a DAMPs family molecule, upon its release from damaged tissues post high dose chemo/radio therapy, triggers activation of donor derived T-cells. Currently, only two published studies evaluated the association between UA levels at day 0 and aGvHD occurrence, with totally conflicting results. Given that aGvHD is a dynamic process which takes place during the whole early post-transplant period, contrasting to previous studies, we evaluated serum UA levels not only once but in 4 different time points during the early transplant period, at days -7, 0, +7, +14, and investigated its correlation to aGvHD incidence, non-relapse mortality (NRM) and survival rates. Methods: We retrospectively evaluated 57 patients (pts), with a median age of 36.8 years (range, 17-62), who underwent allogeneic stem cell transplantation (alloSCT) from full matched sibling donors for malignant (n=48) or non-malignant (very severe aplastic anemia =9) hematological diseases. A median of 5.6 x106/kg CD34+ cells were infused after a myeloablative (n=34) or reduced intensity (n=23) regimen. At the time of alloSCT, 42 pts were in remission (CR1: 30, CR2: 10, &gt;CR2: 2). All pts received either allopurinol or rasburicase from the day of conditioning initiation till day -1. The ROC-curve method, t-test, Kaplan-Meir method, and log-rank test were used for the univariate while the binary logistic regression method for the multivariate statistical analysis. Disease phase [early (CR1) vs. intermediate (CR2) and advanced (&gt;CR2 or presence of residual disease)], donor gender, patient and donor age, UA levels at day -7, 0, +7, +14, type of conditioning regimens and number of infused CD34+ cells were tested as possible factors that can affect aGvHD incidence. Results: Median UA levels were 3.2, 2.4, 2.2 and 2.9 mg/dl at days -7, 0, +7 and +14 respectively; using the ROC curve method the cutoff point was determined at 4.4 mg/dl for day -7 and 2.2 mg/dl for days 0, +7 and +14. Overall, 20/57 (35%) pts developed aGvHD; 18 (31%) were assessed as gr ≥II, while 10 (17%) as gr III-IV. The incidence of the aGvHD gr ≥II was higher for pts with UA levels ≤ 4.4 mg/dl at day -7 (14 vs 4) and for pts with UA levels ≥2.2 mg/dl at days 0 (12 vs. 6 pts) and +14 (13 vs. 5 pts) however these differences did not reach statistical significance. UA levels at +7 day had no impact on aGvHD incidence. In multivariate analysis, only the number of CD34+ &gt;6x106/kg was an adverse factor for aGVHD gr≥II (p=0.04) while intermediate &amp; advanced disease phase along with a number of CD34+ cells &gt;6x106/kg, proved to be significant contributors for severe aGvHD (gr III-IV) occurrence (p&lt;0.03). We observed a better 4 years overall survival for patients with UA levels &lt; 2.2 mg/dl at day +14 (85% vs. 55%, p=0.06). Fifteen pts succumbed to NRM causes; 8/15 deaths were attributed to aGvHD complications. The NRM was higher in patients who had UA levels ≥2.2 mg/dl at day +14 (32% vs. 15%) though this difference was not significant (p=0.2). Conclusions: The present study bears the limitations of a small series of pts and it's retrospective nature. However, it has the advantage of evaluation of UA levels, as an aGvHD mediator, at multiple time points during the peri-transplant period. Our results, though not of strong statistical significance, demonstrated that UA levels might affect aGvHD incidence as well as survival and the NRM rates post alloSCT. Definitely, well designed prospective clinical trials are warranted to clarify the role of UA on alloSCT outcome. Disclosures No relevant conflicts of interest to declare.

Manipulation of Induced Foxp3+ Regulatory T Cells for Prevention of Mouse Acute Graft-Versus-Host Disease

Background Foxp3+ regulatory T cells (Tregs) comprise of natural (n) and induced (i) Treg subsets play an important role in immune system. Currently, isolation of nTregs and in vitro-expanded nTregs was shown to be an effective therapy to GVHD patients. However, shortage of nTregs in peripheral blood and time consumption of expansion in vitro may eventually limit the clinical application. Conversely, iTregs can be generated in vitro from naïve T cells and to a large number of iTregs in short time. As we known, regulatory T cells would decay after a period of time, in vivo or in vitro. Keeping a certain number of iTregs during the GVHD treatment is necessary, it should be the best to provide iTregs to the patient more than single usage. Aim Manipulated supplements of TGF-β1-induced Foxp3+ regulatory T cells should be a good way for prevention from acute graft-versus-host disease within a short time. Investigation was performed via animal model. Methods Splenocytes from C57BL/6 mice were used as a source of naïve T cells by a CD4+ naïve T cell isolation Kit. To induce Foxp3+ regulatory T cells (iTregs), the CD4+ naïve T cells were incubated with anti-CD3/CD28 coated 24-well plate in the presence of IL-2 (20U/ml) and TGF-b1 (50ng/ml) for 3 days. Foxp3+iTregs were harvested and identified as the expressions of CD4+/CD25+/FoxP3+/CD127- via flow cytometry (Fig.1). In this experiment, recipients (BALB/c) were irradiated with 800cGy and then infused with donor (C57BL/6) bone marrow cells with (TCD-BM+CD4T) or without donor T cells (TCD-BM) by intravenous injection. TCD-BM+CD4T cells mice would appear aGVHD phenotype. 8x106 Foxp3+ iTregs were injected into the TCD-BM with donor T cell mouse one or twice (TCD-BM+CD4 T +iTreg) for immunosuppression assay as shown in Fig.2. Mouse GVHD phenotype, body weights and survival rates were investigated lasting for over 90 days. Tissue sections were stained with haematoxylin-eosin. Results According to our preliminary data, it indicated the injection of iTregs in the prevention of aGVHD should be feasible (Fig.3). Consequently, we have tried to investigate preventative efficiency of repeated iTregs supplements in TCD-BM mice. First of all, we compared the single-dose of iTregs with the repetition-dose of iTregs in aGVHD prevention. The data showed in Fig.4. The data showed that the survival rate was 73.3% in repeated treatment in mice, however, the survival rate was only 45.8% in single-dose of iTregs mice within 24 days. As the TCD-BM survival rate was 76.1%. It indicated that the repetition-dose of iTregs would prevent the occurrence of aGVHD, and the survival rate was similar as the bone marrow transplantation mice. The BM-CD4T mice with aGVHD phenotype could survive no more than 10 days. Furthermore, we investigated the survival time of the continual iTreg supplements mice. The data showed in Fig.5. After 90 days later, the body weight of iTregs treated mice could maintain the recovery efficiency to 83.8±2.1% and the survival rate to 78%, comparing with the TCD-BM mice was 88.8±0.6% and 73%. All of these mice could keep alive more than 90 days. Using histographic staining, we confirmed the aGVHD prevention with repeated supplement of Foxp3+iTregs to the CD4T mice (Fig.6). The mice, administration of CD4T cells with bone marrow cells, failed to survival for the serious damage of intestine villi (Fig.6A) and Peyer's patches (Fig.6B). In contrast, CD4T mice with Foxp3+-iTregs (iTregs) could survival more than 90 days and intestine villi were recovered after 90 days (Fig.6A). Peyer's patches are an important gut associated lymphoid tissue in small intestine and play a crucial role in immune response. Therefore, we have investigated the changes of Peyer's patches (Fig.6B). As the recovery of mice with iTregs for twice, the Peyer's patches reappeared after 90 days later. It indicated that keeping more iTregs in vivo could more efficient on prevention of aGVHD. It indicated that more alive iTregs to prevent GVHD occurrence more efficient and may provide the information pre-clinically. Conclusion We showed that repetition supplement of iTreg cells to TCD-BM+CD4T-treated mice, could maintain the mice in high survival rate. Therefore, we may provide more of the functional iTregs to GVHD patients, continuously. It's a good way to prevent the occurrence of GVHD. The result should develop a novel-cell based approach for potentially reducing the risk of acute GVHD clinically. Disclosures No relevant conflicts of interest to declare.

A GUT Microbiota Score Predicting for ACUTE GRAFT-Versus-Host Disease

Although some studies have reported that intestinal microbiota is associated with aGVHD, they inadequately lacked a satisfactory method for precisely predicting aGVHD occurrence. We collected stool and blood samples at day 15 post-transplantation from 150 patients, who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) from two independent centers. Stool microbiota was detected by 16S rRNA gene sequencing, inflammatory factors in blood were detected by multiplex immunoassays, and T lymphocyte subsets were examined by flow cytometry. A gut microbiota score (GMS) from a LASSO (least absolute shrinkage and selection operator) model using the gut microbiota was developed and validated to predict aGVHD. The discovery cohort included most of the identified bacterial families. As determined by area under the curve (AUC) analysis of ROC plots, the GMS could predict aGVHD in grades II-IV (AUC = 0.904, P &lt; 0.0001). Furthermore, the GMS model in the validation set also demonstrated a high AUC that was consistent with the discovery set (AUC = 0.887, P &lt; 0.0001). The results also indicated that the ratio of Treg/Th17 cells in the low GMS subgroup was higher compared with the high GMS subgroup (P = 0.012), and the validation set was consistent with the discovery set (P = 0.003). In addition, high cytokine levels (including IL-1β, IL-6, IL-17, and TNF-α) were associated with high GMS. In conclusions, the GMS at neutrophil engraftment could predict the subsequent aGVHD, and it is a potential and novel method. The GMS was associated with the inflammatory factor levels and Treg/Th17 balance. Disclosures No relevant conflicts of interest to declare.

Premature cyclosporine cessation and TBI-containing conditioning regimen increase the risk of acute GvHD in children undergoing unrelated donor hematopoietic stem cell transplantation.

Acute graft-versus-host disease (aGvHD) is a potentially fatal complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Identifying its risk factors would enable the proper prophylaxis and management, which may significantly improve the general outcome of children treated with HSCT. The aim of this single-center, retrospective cohort study was to assess the potential risk factors for grades II-IV of aGvHD in children after the 1st allo-HSCT from an unrelated donor (UD), performed as a result of an underlying malignant disease. From among patients who received HSCT in our center in the years 2004-2015, 237 were included in the study cohort. All the patients received standard aGvHD prophylaxis consisting of cyclosporine (CsA) and a short course of methotrexate (MTX). Various clinical and epidemiological features, the transplant proceedings, graft composition, conditioning regimens, as well as the duration and coherence of aGvHD prophylaxis were analyzed as potential risk factors for aGvHD. The incidence of II-IV aGvHD in the study cohort was 58.6%. The median time of the diagnosis of aGvHD was 18 days post-HSCT. In the multivariate analysis, risk factors significantly associated with grades II-IV of aGvHD were: myeloablative conditioning regimen containing total body irradiation (TBI-MAC) (RR (relative risk): 1.69; p = 0.03), premature termination of CsA administration due to its toxicity (RR: 1.99; p = 0.0003) and HSCT performed before the year 2009 (RR: 1.97; p = 0.0001). Donor and recipient age, donor-recipient sex mismatch, stem cell source, risk of disease, and amount of infused CD34+ cells seem to be insignificant as risk factors for aGvHD. The overall survival (OS) of patients with aGvHD was noticeably worse that in those who were aGvHD-free: 60.8% vs 74.1% (p = 0.08). The conditioning regimen and the proper aGvHD prophylaxis, including continuous CsA administration, have a major impact on aGvHD occurrence. According to our results, the termination of CsA therapy should be carefully considered, and avoided if possible.

Alteration of the Intestinal Microbiota by Broad-Spectrum Antibiotic Use Correlates with the Occurrence of Intestinal Graft-versus-Host Disease.

Patients undergoing hematopoietic stem cell transplantation (HSCT) frequently receive empiric antibiotics during the neutropenic period before engraftment. Several recent studies have shown that anaerobes in the intestine are important mediators of intestinal homeostasis, and that commensal bacteria can be potent modulators of the severity of acute graft-versus-host disease (aGVHD). However, the relationships among the type of antibiotic used during the neutropenic period, changes in the intestinal microbiota, and subsequent occurrence of aGVHD are not clear. In this study, a total of 211 patients undergoing HSCT were stratified into 3 groups: patients not treated with any antibiotics during the neutropenic period (group 1; n = 43), patients treated with cefepime only (group 2; n = 87), and patients treated with carbapenem antibiotics, defined as meropenem or prepenem with or without previous cefepime therapy (group 3; n = 81). Intestinal microbiota analyses were performed on pre- and post-HSCT stool samples, and immunophenotypic analyses were performed on pre- and post-HSCT peripheral blood samples. Among the 211 patients, 95 (45%) developed aGVHD (grade ≥II), including 54 with intestinal GVHD. The incidence of intestinal GVHD was higher in group 3 compared with group 1 and group 2 (32.1%, 11.6%, and 26.4%, respectively; P = .044). After adjusting for potentially significant variables identified by univariate analysis, multivariate analyses identified broad-spectrum antibiotic use during the neutropenic period as associated with the occurrence of intestinal GVHD (hazard ratio, 3.25; 95% confidence interval, 1.13 to 9.34; P = .029). Accordingly, loss of bacterial diversity in terms of alterations in intestinal microbiota after HSCT was observed in patients who received broad-spectrum antibiotics. Moreover, alterations in the frequencies of several intestinal bacteria phyla were associated with the occurrence of intestinal GVHD. Evaluation of circulating immune cell subsets according to type of antibiotic used during the neutropenic period revealed delayed recovery of myeloid-derived suppressor cells in the broad-spectrum antibiotic use group. Our data indicate that the use of broad-spectrum antibiotics during the neutropenic period is associated with a higher incidence of intestinal GVHD via loss of microbiome diversity. Further studies are needed to determine whether maintaining bacterial diversity can help prevent the development of aGVHD.

Risk Factors Analysis for Human Cytomegalovirus Viremia in Donor+/Recipient+ Hematopoietic Stem Cell Transplantation.

To assess the rate of, and risk factors for, human cytomegalovirus viremia (HCMV) in donor+/recipient+ (HCMV serostatus matched) hematopoietic stem-cell transplantation (HSCT) recipients. HCMV DNA from 144 donor+/recipient+ HSCT recipients was examined by quantitative polymerase chain reaction (qPCR). The cumulative incidence of HCMV viremia was 69.4% (100/144) during the 48 weeks after HSCT. In a multivariate analysis, acute graft-versus-host disease (aGVHD) was discovered to be a risk factor for the occurrence of HCMV viremia (P = .006). The cumulative incidence of HCMV viremia and increasing DNA loads were significantly associated with aGVHD occurrence (P = .001 for each). The occurrence of late-term HCMV viremia was associated with aGVHD (P = .001) and a higher DNA load during the first 12 weeks after HSCT (P = .04). aGVHD is a risk factor for HCMV viremia. Recipients with aGVHD who have a high HCMV DNA load should be strictly monitored to prevent HCMV activation.

Early gut microbiota signature of aGvHD in children given allogeneic hematopoietic cell transplantation for hematological disorders

BackgroundThe onset of acute Graft-versus-Host Disease (aGvHD) has been correlated with the gut microbiota (GM) composition, but experimental observations are still few, mainly involving cohorts of adult patients. In the current scenario where fecal microbiota transplantation has been used as a pioneer therapeutic approach to treat steroid-refractory aGvHD, there is an urgent need to expand existing observational studies of the GM dynamics in Hematopoietic Stem Cell Transplantation (HSCT). Aim of the present study is to explore the GM trajectory in 36 pediatric HSCT recipients in relation to aGvHD onset.MethodsThirty-six pediatric patients, from four transplantation centers, undergoing HSCT were enrolled in the study. Stools were collected at three time points: before HSCT, at time of engraftment and > 30 days following HSCT. Changes in the GM phylogenetic structure were studied by 16S rRNA gene Illumina sequencing and phylogenetic assignation.ResultsChildren developing gut aGvHD had a dysbiotic GM layout before HSCT occurred. This putative aGvHD-predisposing ecosystem state was characterized by (i) reduced diversity, (ii) lower Blautia content, (iii) increase in Fusobacterium abundance. At time of engraftment, the GM structure underwent a deep rearrangement in all patients but, regardless of the occurrence of aGvHD and its treatment, it reacquired a eubiotic configuration from day 30.ConclusionsWe found a specific GM signature before HSCT predictive of subsequent gut aGvHD occurrence. Our data may open the way to a GM-based stratification of the risk of developing aGvHD in children undergoing HSCT, potentially useful also to identify patients benefiting from prophylactic fecal transplantation.

T Regulatory Cells in Donor Grafts May Predict the Severity of Acute Graft Versus Host Disease After Matched Sibling Donor Allogenic Peripheral Blood Stem Cell Transplantation.

Acute graft-versus-host disease (aGVHD) and relapse are major issues for patients undergoing allogenic hematopoietic stem cell transplant (allo-HSCT). T-regulatory (Treg) cells in the donor graft are negatively correlated with the incidence of aGVHD without any impact on relapse. In this study to determine the association of Treg cells with aGVHD in allo-HSCT patients. Thirty-two patients with hematological disorders, who underwent allo-HSCT. Twenty-nine patients who achieved engraftment were enrolled in the study. Treg cells were quantified in donor graft by flowcytometry and were assessed for their association with aGVHD and other clinical outcomes. Fifteen of 29 patients developed aGVHD. According to the occurrence and severity of aGVHD, patients were divided into two groups: 20 (68.9%) patients with grade 0-I aGVHD and 9 (31.1%) patients with grade II-IV aGVHD. Treg cells/CD4 ratio was significantly higher in the grade 0-I aGVHD group than in grade II-IV aGVHD group, (p = 0.0002). We could not find the association of CD34 dose (p = 0.55) or CD3 dose (p = 0.57) with the severity of aGVHD. Higher Treg cells/CD4 ratio in donor graft was associated with less severe aGVHD. Though more studies are needed, Treg cells/CD4 ratio may be used as a predictive marker for severity of aGVHD in post allo-HSCT.

Intestinal Microbiota Can Predict aGVHD Following Allogeneic Hematopoietic Stem Cell Transplantation

Background: The intestinal microbiome plays an important role in the development of acute graft-versus-host disease (aGVHD). However, it is not well known whether the intestinal microbiota at neutrophil engraftment could predict the occurrence and grades of aGVHD. Methods: We collected stool and blood samples from 141 patients undergoing allogeneic hematopoietic stem cell transplantation. The microbiota, the inflammatory factors and T lymphocyte subsets were detected at pre-conditioning, day 0 and day 15 post-transplantation. The abundance of bacterial that could predict aGVHD and diversity were included in accumulated intestinal microbiota (AIM) score. Findings: We found microbiota diversity was associated with conditioning (P = 0.017, day 0 and P = 0.045, day 15) and β-lactam antibiotics (P = 0.004, day 15). Treg/Th17 ratio was positively correlated with microbial diversity (r = 0.216, P = 0.010), while it was negatively correlated with levels of TNF-α, IL-17A, IL-1β and LPS in plasma (r = -0.226, -0.225, -0.335, -0.291; P = 0.007, 0.010, < 0.001, < 0.001, respectively) at day 15. The accumulated intestinal microbiota (AIM) score at day 15 could be a predictor for the development of aGVHD (II-IV aGVHD: AUC = 0.75, P < 0.001; III-IV aGVHD: AUC = 0.84, P < 0.001). AIM score was also correlated with aGVHD grades (r = 0.481, P < 0.001). Interpretations: These findings suggest intestinal microbiota and conditioning might induce aGVHD by inflammatory factors and influence Treg/Th17 balance. The constitution of the intestinal microbiota at neutrophil engraftment may predict the development and grades of aGVHD. Funding: This work was funded by the National Natural Science Foundation of China (Nos. U1401221, 81770190, 81870144, 81600141, 81700176, and 81470349), the National primary research plan (Nos. 2017YFA105500 and 2017YFA105504). Science and Technology Major Planning Project of Guangdong Province (2014B020226004), Natural Science Foundation of Guangdong Province (No.2016A030310390), and Medical Science and Technology Planning Project of Henan Province (201403227). Declaration of Interest: The authors declare no competing financial interests. Ethical Approval: This study was approved by the ethical committee of the Nanfang Hospital, Southern Medical University, China. After approval of the study, the consent of the participants was signed for biospecimen collection and analysis. This study was conducted in accordance with the Declaration of Helsinki.

A Possible Reason to Induce Acute Graft-vs.-Host Disease After Hematopoietic Stem Cell Transplantation: Lack of Sirtuin-1 in CD4+ T Cells.

Sirtuin 1 (SIRT1) is a critical suppressor of T cell immunity. However, whether SIRT1 is involved in the progression of acute graft-vs.-host disease (aGVHD) has still remained unclear. PI3K/Akt/mTOR pathway is a crucial element involved in the activation and functions of T cells. Over-activation of PI3K/Akt/mTOR signaling may be related to the occurrence of aGVHD. STAT3 activation requires phosphorylation and acetylation. A recent study showed that STAT3 hyperphosphorylation in CD4+ T cells may be a trigger of aGVHD. The role of the STAT3 acetylation in aGVHD pathogenesis is still unclear. The present study revealed that SIRT1 deficiency as a critical factor is involved in the excessive activation of mTOR pathway and upregulation of STAT3 acetylation and phosphorylation in CD4+ T cells from patients with aGVHD. Exorbitant activation of IL-1β signaling is the main reason for TAK1-dependent SIRT1 insufficiency. The findings of the present study might provide a new therapeutic target for treating aGVHD.

Mortality, length of stay and costs associated with acute graft-versus-host disease during hospitalization for allogeneic hematopoietic stem cell transplantation

Objective: Acute graft-versus-host disease (aGVHD) is a common and life-threatening complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). The extent to which aGVHD increases inpatient costs associated with allo-HSCT has not been thoroughly evaluated. In this analysis, mortality, hospital length of stay (LOS) and costs associated with aGVHD during allo-HSCT admissions are evaluated.Methods: This is a retrospective analysis of discharge records from the National Inpatient Sample database for patients receiving allo-HSCT between 1 January 2009 and 31 December 2013. Allo-HSCT discharges with an aGVHD diagnosis were included in the aGVHD group and those without any graft-versus-host disease (GVHD) diagnosis comprised the non-GVHD group. Mortality, LOS and costs were compared between the two groups, as well as within subgroups, including age (<18 vs. ≥18 years) and survival status (alive vs. deceased) at discharge.Results: Overall, mortality (16.2% vs. 5.3%; p < .01), median hospital LOS (42.0 vs. 26.0 days; p < .01) and median total costs ($173,144 vs. $98,982; p < .01) were significantly increased in patients with aGVHD versus those without GVHD during hospitalizations for allo-HSCT, irrespective of age group. Patients with aGVHD who were <18 years of age had a lower mortality rate but greater hospital LOS and total costs versus patients aged ≥18 years. Patients who died during allo-HSCT hospitalization had longer LOS and incurred greater costs than those who survived in both the aGVHD and non-GVHD groups.Conclusion: Occurrence of aGVHD during allo-HSCT admissions resulted in a tripling of the mortality rate and a near doubling of hospital LOS and total costs. In addition, death during allo-HSCT hospitalizations was associated with greater healthcare utilization and costs. Effectively mitigating aGVHD may improve survival and substantially reduce hospital LOS and costs for allo-HSCT.