Chronic Graft-versus-host Disease Patients Research Articles

Monocyte Subpopulations and Their Expression of HLA-DR and CD300e after Allogeneic Stem Cell Transplantation in Patients with or without GvHD

Introduction: Graft versus host disease (GvHD) is a complex immune process that can affect up to 50% of patients undergoing allogeneic stem cell transplantation (allo-SCT). Even though prophylactic immunosuppressive regimens have been established over the last decades, GvHD is still one of the main causes of morbidity and mortality among these patients. Monocytes are cells of the innate immune system, that represent, as professional antigen-presenting cells, a connection to the adaptive immune system, and play a role in several autoimmune disorders. They are classified according to the expression of CD14 and CD16 into classical (CD14++/CD16-), intermediate (CD14++/CD16+), and non-classical (CD14+/CD16++) monocytes. Previous research has shown higher levels of intermediate monocytes in pediatric patients with GvHD. Furthermore, non-classical monocytes in allogenic bone marrow grafts have also been correlated with the development of GvHD. The expression of other surface markers such as HLA-DR and CD300e (IREM-2) are related to monocyte function and engagement in inflammatory processes. Nevertheless, the role of CD300e in GvHD remains unclear. Here, we present a description of monocyte subgroups and their expression of HLA-DR and CD300e in allo-SCT patients with or without GvHD as well as in healthy subjects. Methods: Transversal observational study with patients undergoing allo-SCT. Peripheral blood of patients was collected once after engraftment. Both acute and chronic GvHD patients were enrolled. Five healthy volunteers served as controls. Flow cytometry was performed to determine the immunophenotype of monocytes according to their expression of CD14 and CD16 stratifying into classical, intermediate, and non-classical subgroups as described above. In addition, the expression of HLA-DR and CD300e was analyzed for all monocytes and individual subgroups. Clinical characteristics are described in the table below. Statistical analysis was performed using GraphPad Prism 9. Comparisons between groups were made using non-parametrical tests and tests for multiple comparisons (Mann-Whitney and Kruskal-Wallis respectively). Results: 29 patients were enrolled. Two patients with GvHD were excluded due to neutropenia. 19 patients presented GvHD grade II or higher. Of those, ten had acute GvHD, five had prolonged acute GvHD, two had late onset acute GvHD, and two had chronic GvHD. Eight patients did not show GvHD or had only mild skin disease (grade one). The mean age was 60 years for all patients, 62.5 and 58.5 years among GvHD and non-GvDH patients, respectively. The image summarizes patient characteristics and comparisons. We compared transplant recipients with and without GvHD which each other and with healthy controls. In single comparisons, patients with GvHD showed significantly lower percentages of total monocytes as well as CD14+/HLA-DR+, total HLA-DR+, and intermediate monocytes compared to patients without GvHD. In addition, we observed a trend toward lower levels of CD16+/HLA-DR+ and CD300e-expressing monocytes in GvHD patients. When compared to healthy controls, allogeneic recipients without GvHD showed significantly higher levels of total monocytes, intermediate monocytes, and CD16+/HLA-DR+ monocytes and lower levels of classical and non-classical monocytes. Compared to controls, patients with GvHD showed significantly lower levels of total monocytes expressing CD300e (also true in all subgroups) as well as lower levels of classical monocytes, but higher levels of intermediate and non-classical monocytes. P values are shown in Table 1. Means and ranges for all groups are represented in Image 1. Conclusions: In our cohort, patients with GvHD showed higher levels of intermediate and non-classical monocytes compared to controls, however, these populations were lower when compared to allogeneic recipients without GvHD. This could indicate a consumption process similar to that observed in COVID-19 patients and a direct involvement of these monocytes in the GvHD process. In addition, we report for the first time the involvement of CD300e in GvHD, which was significantly lower expressed in the GvHD patients, compared to controls. However, there was only a strong trend compared to transplanted non-GvHD patients. This indicates a possible contribution of CD300e in the pathogenesis of GvHD. Further studies are needed in order to confirm these findings.

Targeting PRMT1 prevents acute and chronic graft-versus-host disease

Graft-versus-host disease (GVHD) is a common complication after allogeneic hematopoietic stem cell transplantation. Recent studies have reported that protein arginine methyltransferase 1 (PRMT1) is essential for the differentiation and proliferation of T and B cells. Therefore, it is possible that PRMT1 may play a critical role in GVHD. In this study, we observed that PRMT1 expression was upregulated in CD4+ T and B cells from chronic GVHD (cGVHD) patients and mice. However, the prophylactic use of a PRMT1 inhibitor significantly prevented cGVHD in mice by reducing the percentage of T helper (Th)17 cells, germinal center B cells, and plasma cells. The PRMT1 inhibitor also controlled acute GVHD (aGVHD) in mice by decreasing the percentage of Th17 cells. Moreover, inhibiting PRMT1 also weakened Th17 cell differentiation, B cell proliferation, and antibody production in cells from cGVHD patients. Additionally, further studies revealed that PRMT1 regulated B cell proliferation and antibody secretion by methylating isocitrate dehydrogenase 2 (IDH2). We observed asymmetric di-methylation of IDH2 by PRMT1 at arginine 353 promoted IDH2 homodimerization, which enhanced IDH2 activity, further increasing B cell proliferation and antibody production. Collectively, this study provides a rationale for the application of PRMT1 inhibitors in the prevention of aGVHD and cGVHD.

Estimating the Lifetime Medical Cost Burden of an Allogeneic Hematopoietic Cell Transplantation Patient

Allogeneic hematopoietic cell transplantation (allo-HCT) has the potential for curative outcomes for a variety of hematologic malignancies. Current allo-HCT studies often describe the outcomes and costs in the near term; however, research on the lifetime economic burden post-allo-HCT remains limited. This study was conducted to estimate the average total lifetime direct medical costs of an allo-HCT patient and the potential net monetary savings from an alternative treatment associated with improved graft-versus-host disease (GVHD)-free, relapse-free survival (GRFS). A disease-state model was constructed using a short-term decision tree and a long-term semi-Markov partitioned survival model to estimate the average per-patient lifetime cost and expected quality-adjusted life years (QALYs) for an allo-HCT patient from a US healthcare system perspective. Key clinical inputs included overall survival, GRFS, incidence of both acute and chronic GVHD, relapse of the primary disease, and infections. Cost results were reported as ranges based on varying the percentage of chronic GVHD patients that remained on treatment after 2 years (15% or 39%). Over a lifetime, the average per-patient medical cost of allo-HCT was estimated to range from $942,373 to $1,247,917. The majority of the costs were for chronic GVHD treatment (37% to 53%), followed by the allo-HCT procedure (15% to 19%). The expected lifetime QALYs of an allo-HCT patient were estimated as 4.7. Lifetime per-patient treatment costs often exceed $1,000,000 for allo-HCT patients. Innovative research efforts focused on the reduction or elimination of late complications, particularly chronic GVHD, may provide the greatest value to improved patient outcomes.

Estimating the Lifetime Medical Cost Burden of an Allogeneic Hematopoietic Cell Transplantation Patient and the Value of Addressing the Unmet Need

Background: Allogeneic hematopoietic cell transplantation (allo-HCT) management has evolved, with the emergence of molecular detection assays and therapies to treat post-HCT complications such as graft-versus-host disease (GVHD). However, this approach could increase the economic burden on healthcare systems by only managing complications that occur after the initial transplant. Instead, alternative therapies involving novel engineered donor allografts to replace standard allo-HCT to prevent late complications may potentially improve outcomes and address a greater unmet need. Objective: To estimate (1) the average total lifetime medical costs of an allo-HCT and (2) to estimate the net monetary savings and value associated with reducing late complications. Methods: A short-term decision tree (100-day) and a long-term semi-Markov partitioned survival model were developed that estimated the average per-patient lifetime cost and expected quality-adjusted life years (QALYs) for an allo-HCT patient from a United States healthcare system perspective. The allo-HCT patient population represented an average 53-year-old patient who was undergoing an allo-HCT to treat the three most common indications for allo-HCT: acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), or myelodysplastic syndromes (MDS), distributed as 51%, 21%, and 28%, respectively. Key model clinical inputs included: overall survival, GVHD-free relapse-free survival (GRFS), incidence of both acute and chronic GVHD, relapse of the primary disease, and infections. Following the first 100 days, the patient cohort was assigned to 3 mutually exclusive health states in a semi-Markov partitioned survival model for the remainder of their lifetime: (1) GRFS, (2) progressed and/or GVHD, and (3) death. The projected time spent in each health state was derived from data provided by CIBMTR. Costs pertaining to allo-HCT and associated complications were obtained from the published literature based on medical claims analyses of payments (paid amounts) and were converted into costs using the American Hospital Association (AHA) commercial payment-to-cost ratio. Maintenance therapy costs for FLT3-ITD positive AML and Ph+ ALL cases were also included and were based on published literature, expert opinion, and prescribing information. The key outcomes were direct medical costs and expected QALYs. Cost results were reported as a range based on varying the percent of chronic GVHD patients that remained on treatment after two years (15% or 39%) as derived from the published literature. Scenario analyses were conducted to estimate the potential clinical and economic value that may be realized by improving GRFS outcomes. The scenario analyses to address some of the unmet need were modeled as a doubled improvement in GRFS (69% GRFS in year 1 as opposed to 34%) to estimate changes in allo-HCT-associated costs and survival. A willingness-to-pay threshold of $150,000 was used to monetize the QALYs gained as a result of improving GRFS outcomes. Results: Over a lifetime, the average per-patient medical cost of allo-HCT was estimated to range from $942,373 to $1,247,917. Of those total costs, 23% to 30% were incurred within the 1st 100 days and 42% to 56% within the 1st year. Of the medical costs estimated, the majority of the costs were for chronic GVHD treatment (37% to 53%) followed by the allo-HCT procedure (15% to 19%). Expected lifetime QALYs of an allo-HCT patient were estimated to be 4.7. In the scenario analyses, the unmet need that could be addressed by improving GRFS outcomes (via the medical cost offsets and QALYs gained) was associated with a net monetary value that ranged from $695,709 to $911,062. Of the estimated net monetary value, 85% to 88% was driven by direct medical cost savings while the remaining 12% to 15% was due to value of the gain in expected QALYs. Conclusions: The current per-patient cost of allo-HCT carries a substantial medical cost burden often exceeding $1M over the lifetime of the patient. Innovative research efforts focused on disease control and reduction or elimination of late complications altogether, particularly cGVHD, may provide the greatest value in improved patient outcomes and reduced healthcare spending. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

P1382: RUXOLITINIB USE IN A REAL WORLD ACUTE AND CHRONIC GRAFT VERSUS HOST DISEASE COHORT IN THE NETHERLANDS: A RETROSPECTIVE STUDY

Background: Preclinical data showed that Janus Kinase (JAK) signaling plays an important role in the pathogenesis of Graft versus Host Disease (GVHD) and several clinical studies showed remarkable clinical efficacy in both acute and/or chronic steroid-refractory (SR)-GVHD patients. However, these clinical results have not yet been repeated in real world cohorts with long term follow-up. Furthermore, infectious complications have not been highlighted in published clinical trials whilst these remain a significant problem in daily practice. Aims: To assess the response of acute and/or chronic SR-GVHD patients to ruxolitinib treatment and to assess side-effects of ruxolitinib treatment occurring in adult acute and/or chronic SR-GVHD patients. Methods: We performed a retrospective analysis of 121 consecutive patients treated with ruxolitinib for either acute or chronic GVHD. Patients were included from 3 academic centers in the Netherlands from 2014 to 2019. Patients provided written informed consent, with the exception of deceased patients in accordance with the local ethics committee. Patient data were extracted by personnel from an independent CRO to minimize reviewer bias. Patient data were anonymized. Results: 121 patients were included in the study of whom 54 were diagnosed with acute and 67 patients with chronic GVHD. Selected baseline characteristics are depicted in Table 1. The overall response rate at day 28 of acute GVHD was 70% (38/54) with a complete response in 50% of patients (27/54). At timepoint 6 months after initiation of ruxolitinib for chronic GVHD, the majority of patients showed stable disease. The overall response rate at 6 months in chronic GVHD was 28% (19/67) with a complete response in 13% of patients (9/67). Ruxolitinib use was mainly complicated by infections and hematological toxicity. Of the reported (S)AE’s possibly related to ruxolitinib, 38% were infectious and 13% were hematological. Severity of infections ranged from grade 1 to grade 5, median grade 2. Most infections were viral (43%), followed by bacterial (19%) and fungal or mould infections (14%). During follow up mortality was 14,9% (18 patients) of which 6 cases were due to uncontrolled GVHD, 5 cases due to infections and 3 patients died of relapse of their primary malignancy, 4 patients died of other causes. Image:Summary/Conclusion: In a real world cohort of GVHD patients treated with ruxolitinib we observed in patients with acute GVHD a complete response rate at day 28 of 50%. Overall response rate at 6 months in cGVHD patients was 28%. Infectious adverse events were common in both acute and chronic GVHD patients and were mainly caused by viral pathogens.

Kolonda nadir bir darlık ve ülser nedeni: Kronik graft versus host hastalığı

Dear Editor;
 Often during routine gastroenterology examinations, ulcers and strictures in the colon and small intestine are encountered in patients. Differential diagnosis of ulcers in these patients may not always be easy. Graft-versus-host disease (GVHD) is a serious complication that can be life-threatening after allogeneic bone marrow transplantation (1). Since the introduction of modern immunosuppressive treatment regimens, clinical symptoms, radiographic and histological findings are rarely seen in chronic graft-versus-host disease (CGVHD) (2). However, CGVHD patients often present with various gastrointestinal symptoms such as esophageal reflux, dysphagia, bloating, weight loss, and diarrhea (2). Edema, erythema, diffuse polypoid lesions, multiple ulcers, and strictures in the mucosa can be observed in the endoscopic examination of intestinal GVHD (3). 
 We present a patient who was diagnosed with CGVHD in a colonoscopic examination performed for iron deficiency anemia. 
 A 52-year-old female patient was referred to our gastroenterology outpatient clinic for endoscopic examination after the laboratory tests revealed iron deficiency anemia. The patient's medical history revealed that she had undergone autologous stem cell transplantation in 2012 and allogeneic stem cell transplantation in 2016 with a diagnosis of Non-Hodgkin lymphoma. A hysterectomy had been performed due to myoma. 
 When the patient's complaints were questioned, there were no gastrointestinal complaints such as bloating, constipation, diarrhea, or abdominal pain. Physical examination revealed multiple psoriasis colored rashes on the skin on the neck and nape (Figure 1). White blood cell count in laboratory tests: 8920 x103/μL, platelet: 470 x103/μL, Hgb: 10.9 g/dl, aspartate aminotransferase: 47 U/L, alanine transaminase: 39 U/L, alkaline phosphatase: 99 U/L, total bilirubin: 0.56 mg/dl, albumin: 4.2 g/dL, serum iron: 115 u/dl, total iron-binding capacity: 274 u/dl, ferritin: 12 u/L, vitamin B12: 353 ng/L were detected.
 The colonoscopic examination showed that, in the ascending colon, the lumen was narrowed fibrotically, not allowing the endoscope to pass proximally (Figure 2). In addition, multiple ulcerated lesions extending perpendicular to the lumen, covered with white exudate, causing shrinkage in the mucosa, and approximately 5-6 mm diameter were observed in the ascending colon, transverse colon, and descending colon (Figure 3). In the pathological examination of the biopsies taken from the lesions, the patient was diagnosed with CGVHD after intense inflammation in the lamina propria. Apoptosis in the crypts was observed, and cytomegalovirus (CMV) was excluded (Figure 4).
 Endoscopic images of GVHD-induced gastrointestinal involvement vary, and the involvement of lesions may be focal or diffuse (4,5). Various lesions such as mild mucosal erythema, edema, prominent ulcers, lytic mucosal lesions can be seen in the upper and lower gastrointestinal tract (GIS) in endoscopic evaluation. The demonstration of apoptosis is very supportive for diagnosis. The diagnosis of gastrointestinal GVHD is made by endoscopic examination and mucosal biopsy, in the endoscopic biopsy (3). Other causes of apoptotic colopathy, especially CMV, should be considered in the differential diagnosis. Thus, chronic GVHD should be considered in the differential diagnosis of strictures and ulcers in a colonoscopic examination.

16248 Vitiligo as a chronic cutaneous graft-versus-host disease

Chronic graft-versus-host disease (GVHD) is a systemic disease with prominent cutaneous manifestations. Other cutaneous autoimmune conditions have been well characterized as posttransplantation complications, however vitiligo is very rare. We investigated clinicopathologic features of patients who developed vitiligo as a manifestation of chronic cutaneous GVHD and analyzed clinical correlation between vitiligo-like lesion and chronic cutaneous GVHD. We recruited chronic cutaneous GVHD patients with vitiligo-like lesion from 2000 to 2019 and performed histopathologic examination on their vitiligo lesions with immunohistochemical stain for melan A. Total 37 patients were diagnosed as chronic cutaneous GVHD and 13 chronic GVHD patients presented with vitiligo were identified. There were 12 male patients and only one female patient. The age ranged from 2 to 49 years with a mean age of 28 years. Underlying diseases were leukemia in 9 patients. All patients developed vitiligo as a manifestation of chronic GVHD which occurred at a mean duration of 11.25 months (6-24 months) after transplantation. Immunohistochemical stain for melan-A performed were negative in 5 patients. Furthermore, 4 of 5 patients who were negative for melan-A presented with vitiligo only, neither lichenoid nor sclerodermoid manifestations. We concluded that vitiligo might be an important chronic cutaneous GVHD spectrum as an extension of the lichenoid and sclerodermoid type.

Safety and Efficacy of Ruxolitinib in Steroid-Resistant Graft Versus Host Disease: A Systematic Review and Meta-Analysis

Introduction: Stem cell transplantation (SCT) is used to treat multiple malignancies, but a major complication of the procedure is graft versus host disease (GvHD), which is a significant cause of morbidity and death in SCT patients. Methylprednisolone is the first-line therapy of GvHD. Ruxolitinib is a Janus kinase (JAK) inhibitor that can dampen the effect of inflammatory cytokines involved in GvHD and may be used in patients refractory to steroid treatment. In this systematic review and meta-analysis, we assessed the safety and efficacy of Ruxolitinib in steroid-resistant (SR) acute (a) and chronic (c) GvHD. Methods: We performed a search on PubMed, Cochrane, Embase, and Web of Science. We used the keywords, "Ruxolitinib" AND "Graft vs Host Disease" from the inception of literature till 7/10/2020. We screened 694 articles and included 1 randomized clinical trial (RCT) (N=309), 4 non-randomized trials (NRCT) (N=232), and 13 observational studies (N=481) in this meta-analysis. We extracted data for efficacy (i-e, OS, CR, ORR) and safety (≥grade 3 treatment related adverse events (TRAE). We excluded case reports, case series, review articles, meta-analysis, and preclinical trials. We used the R programming language (version 4.0.2) to conduct a meta-analysis. Results: In the 18 included studies (N=1022), Ruxolitinib was used in patients with the age range of 6 months to 70 years. 417 participants had grade III-IV acute GvHD, and 272 participants had moderate to severe chronic GvHD (Table 1). In an RCT (N=309), patients aged between 12-73 years with SR aGVHD were randomized 1:1 to receive either Ruxolitinib or physician's choice drug. Overall response rate (ORR) and complete response (CR) were significantly higher in the Ruxolitinib group as compared to the physician's choice drug. The results were consistent for all grades of GvHD. Grade 3 or higher treatment-related adverse events (TRAEs) were 78% in the two groups. 22% of the patients died of GvHD related adverse events in the Ruxolitinib group vs. 25% of the patients in the control group. In 12 clinical trials and observational studies, among SR GvHD patients (N=443), pooled ORR was 0.74 (CI=0.65-0.81, I2=61%) with Ruxolitinib treatment. Similarly, pooled CR was 0.45 (CI=0.34-0.68, I2=81%). The most common adverse events were cytopenias, viral reactivation, and infections. (Fig 1, 2) In 9 early phase trials and observational studies (N=282) in SR- chronic GvHD patients, pooled ORR and pooled CR were 0.75 (CI=0.64-0.83, I2=64%) and 0.11 (CI=0.08-0.16, I2=0), respectively. The most common adverse events were cytopenias and viral reactivation (Fig 3, 4). In a non-randomized trial (N=64), Ruxolitinib was used in combination with Etanercept for SR- acute GvHD patients. The ORR and CR were 87.5% and 72%, respectively. High rates of hematological adverse events and infections were reported in these patients. In an observational study (N=18), Ruxolitinib was used in combination with Extracorporeal Photopheresis (ECP). The combination was well-tolerated, and ORR and CR were 55% and 44%, respectively (Table 1). Conclusion: Ruxolitinib was well tolerated by patients with acute or chronic SR-GvHD. Ruxolitinib showed a higher efficacy compared to the physician's choice drug in SR acute GvHD. Ruxolitinib was also effective in SR cGvHD patients. The addition of etanercept to Ruxolitinib increased the efficacy in SR-acute GvHD patients but resulted in an increased incidence of infections. Ruxolitinib with ECP was effective and well tolerated in SR-acute GvHD. Additional multicenter, randomized, double-blind clinical trials are needed to confirm these results. Disclosures Anwer: Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau.

Allogeneic Bone Marrow Mesenchymal Stromal Cell Therapy in Patients with Steroid-Refractory Graft Versus Host Disease—a Pilot Study from Pakistan

Mesenchymal stromal cells (MSCs) have emerged as a promising candidate for the treatment of steroid-refractory graft-versus-host disease (GVHD). In this uncontrolled, pilot clinical study, we report safety and efficacy of allogeneic bone marrow MSCs administered intravenously to steroid-refractory GVHD patients. A total of 33 MSC infusions were given to 10 patients suffering from acute GVHD (n = 3), chronic GVHD (n = 5), and overlap syndrome (n = 2). Eight out of ten patients are alive after a median follow-up of 11 months with five having sustained complete remission (CR). Three patients with partial response received further doses to sustain the response. One of them died of lung infection while others are still alive. One out of the two non-responding patients died after 17 days of MSC therapy due to advanced liver GVHD while the other is having a stable disease course. The overall and GVHD-free survival was 80% and 50%, respectively. The patients developed no complication or toxicity related to MSC infusion. Luminex analysis revealed a modest drop after MSC infusion in pro-inflammatory cytokines like TNFα, IL-1β, and IL-6 whereas serum IL-10 levels were slightly raised. Allogeneic donor-derived bone marrow mesenchymal stromal cell therapy is a safe and feasible treatment for steroid-refractory GVHD patients (NCT02824653). We report the safety and efficacy of allogeneic bone marrow mesenchymal stromal cell therapy in 10 patients suffering from steroid-resistant graft-versus-host disease. Eight out of ten patients are alive after a median follow-up of 11 months with five having sustained CR. The response rate was better in acute GVHD patients compared to chronic GVHD patients. MSC therapy within 20 days of steroid-refractory acute GVHD resulted in sustained CR. Initial and sustained response was superior in pediatric patients compared to adults. The Luminex analysis showed a modest decrease in pro-inflammatory cytokines in those responding to MSC therapy.

Systematic Review of Patient-Reported Outcome Measures in Graft-versus-Host Disease.

Graft-versus-host disease (GVHD) is a major cause of morbidity and mortality after allogeneic stem cell transplantation. These patients face a unique challenge due to the complexity of GVHD and the toxicity of treatments received. GVHD has significant impact on quality of life (QOL), but this is not routinely evaluated formally. Despite the availability of patient-reported outcome measures (PROMs) to assess QOL, there is currently no consensus regarding the optimal PROMs that should be used to evaluate the impact of GVHD. We undertook a systematic review to determine the current evidence for the use of PROMs in assessment of QOL, symptom burden, and disease severity of patients with GVHD. A comprehensive systematic review based on the COSMIN guidelines was conducted to identify studies using PROMs (including those for QOL and symptom burden) in acute and chronic GVHD (cGVHD) patients. The following databases were searched: OVID Medline, AMED, CINAHL, Embase, PROQOLID, ProQuest, PsychINFO, and Social Sciences Citation Index from inception to May 2018. Hand searches updated the search to December 2018. Articles were screened by 2 independent reviewers, with discrepancies resolved by a third independent reviewer. Included articles were critically appraised using the COSMIN Risk of Bias tool, and relevant data on measurement properties for the included PROMs were extracted from within the target population. A total of 4545 articles were identified, and 64 articles reporting on 27 PROMs were included in this review. PROMs were separated into 5 groups; generic patient-reported measures (n=7), cancer-specific measures (n=4), bone marrow transplant-specific measures (n=2), cGVHD-specific measures (n=4), and dimension-specific measures (n=10). Three PROMs (Human Activity Profile, Lee Symptom Scale, National Institutes of Health Eleven Point Scale) had evidence to support strong reliability (including internal consistency), responsiveness, and aspects of validity within the cGVHD population. Only 5 included PROMs were used in patients with acute GVHD. This review summarizes the current evidence regarding the use of 27 included PROMs in the context of GVHD. The choice of the most optimal PROM depends on the clinical or research context of use. Future research should comprehensively validate these tools in the GVHD population, including the testing and possible development of a PROM for use in acute GVHD, which remains a current critical gap in the existing literature.

Tear cytokine levels in the diagnosis and severity assessment of ocular chronic graft-versus-host disease(GVHD)

PurposeTo analyse the tear cytokine levels of patients diagnosed with ocular chronic graft-versus-host disease(GVHD)and examine the consistency of these levels with different ocular surface parameters. Methods23 ocular chronic GVHD patients were selected for the assessment of tear cytokine levels and ocular surface parameters (TBUT, CFS, OSDI, and Schirmer's test), and 16 dry eye disease(DED)patients without systemic immune disease were selected as the control group. The 23 cytokines were measured using microsphere-based immunoassay analysis and their consistency with different ocular surface parameters was studied. ResultsICAM-1, IL-1β, IL-6, and IL-8 showed elevated levels in the eyes of oGVHD patients compared to DED [P < 0.001]. IL-7 and EGF showed lower levels in the eyes of patients with oGVHD than in those of patients with DED [P < 0.0001]. Furthermore, the levels of IL-6 and IL-8 showed a stronger correlation with corneal fluorescein staining (CFS) (P < 0.05), and the levels of IL-6 and ICAM-1 were most consistent with fluorescein tear film break-up time (TBUT) (P < 0.05). ConclusionsOur study demonstrated certain tear cytokines, including ICAM-1, IL-1β, IL-6, IL-8 IL-7 and EGF, as promising new possible diagnostic markers of chronic oGVHD and criteria for chronic ocular GVHD severity. Because tear sampling is noninvasive and simple, this method is expected to be an overwhelming applicable for the screening and diagnosis of chronic GVHD.

The CELLEX is comparable to the UVAR-XTS for the treatment of acute and chronic graft versus host disease (GVHD).

Two extracorporeal photopheresis (ECP) instruments, the CELLEX and the UVARXTS are currently being used "off-label" in the US for treatment of graft versus host disease (GVHD). Our study compared the performance of the two instruments in the setting of acute and chronic GVHD. We retrospectively analyzed the outcomes of patients with steroid refractory or steroid resistant GVHD undergoing ECP at Barnes Jewish Hospital. Multivariate logistic regression was used to evaluate the comparative efficacy of the two instruments with respect to steroid dose reduction (≥50% from baseline) and clinical improvement in GVHD. Chi-square/Fisher exact tests were used to compare the incidence of adverse events, while multivariate Cox regression was employed to assess a potential difference in mortality between the two instrument treatment cohorts. After adjusting for potential confounders, there was no significant difference in the odds of steroid dose reduction (OR = 1.41, 95% confidence interval [CI]: 0.51-3.90, p = 0.50) or clinical improvement (OR 2.0, 95% CI: 0.63-6.41, p = 0.24) between the two instrument treatment cohorts. The frequency of adverse events (CELLEX 45.4%; UVAR XTS 40.5%, p = 0.55) was also comparable between the cohorts. There was no significant difference in mortality of either acute or chronic GVHD patients when treated by the CELLEX as compared to the UVAR-XTS (aHR 0.66, 95% CI: 0.35-1.25, p = 0.20). The efficacy and safety of the two ECP instruments, the CELLEX and the UVAR-XTS, are comparable for the treatment of acute and chronic GVHD.

Graft Versus Host Disease (GVHD) after HLA-Mismatched Haploidentical Transplantation with Post-Transplant Cyclophosphamide Compared to Matched Unrelated Donor: Incidence, Distribution and Response to Therapy

Unmanipulated T-cell replete HLA-mismatched haploidentical transplantation (haplo) with post-transplant cyclophosphamide (PTCY) is now widely used for patients lacking a suitably matched donor. The use of PTCY post haplo results in lower chronic GVHD rates compared to match unrelated donors (MUD) without PTCY. GVHD after PTCY in the haplo setting may have different presentation, response to treatment and impact on survival endpoints compared to a standard GVHD prophylaxis of calcineurin inhibitor plus MMF or methotrexate for MUD patients. To check for differences in GVHD presentation and response to treatment between MUD and haplo with PTCY, we assessed 394 consecutive patients who developed acute or chronic GVHD after receiving their first allogeneic transplantation (HCT) from a 10/10 HLA MUD (n=179) or a haplo (n=215) at our center between 2008 and 2017. Median follow up for survivors was 52.5 months. Our institution has prospectively documented onset, grading and therapy of patients with GVHD using a single dedicated practitioner since 2005. All haplo patients received standard GVHD prophylaxis of tacrolimus (days 5-180), MMF (stop day 35) and PTCY at 50mg/kg on days 3 and 4. Most commonly used GVHD prophylaxis for MUD patients were tacrolimus/methotrexate (68%) and tacrolimus/MMF (26%). MUD recipients were older (median age 56 vs 53 years, p=0.007), were more likely to be white (93% vs 58%, p&lt;0.001), received mainly PBSC as graft source (76% vs 63%, p0.013) and had a higher HCT-comorbidity index (HCT-CI≥3, 64% vs 47%, p&lt;0.001) compared to haplo recipients. The cumulative incidences for grade II-IV and III-IV aGVHD at day 180 post HCT were similar between both donor sources at 35% and 11% for haplo compared to 44% and 16% for MUD (p=NS). Haplo patients had lower cumulative incidence of mod-severe cGVHD at 22% versus 31% for MUD (p=0.026).The median times to onset of grade II-IV acute GVHD and moderate-severe chronic GVHD were: acute, 56 vs 49 days (p=0.19) and chronic 213 vs 280 days (p=0.011) for haplo versus MUD patients respectively. Among patients with grade II-IV acute GVHD, there was no significant difference in organ involvement between Haplo (n=101) and MUD (n=96) with skin being most commonly affected (74% haplo vs 71% MUD), Gut (70% haplo vs 69% MUD) and liver (14% haplo vs 17% MUD). For patients who developed chronic GVHD, organ involvement distribution is shown in table 1. Haplo patients had less involvement of the eyes (46% vs 75% for MUD, p&lt;0.001) and of the joints/fascia (12% vs 36%, p=0.001). Among patients who developed grade II-IV acute GVHD, there was no difference in all-cause mortality (28% vs 19%, p=0.34) and being off immunosuppression at one 1 year (49% vs 51% p=0.80) between haplo and MUD recipients. Among patients who developed cGVHD, haplo recipients had similar all-cause mortality (22% vs 18%, p=0.89) but were more likely to be off immunosuppression at 2 years post HCT (63% vs 43% p=0.03) compared to MUD (figure 1). A cox model was conducted on survival and relapse endpoints where donor type was retained in all models. The fixed covariates tested in Cox models included age (&lt;55, &gt;=55), gender, race, diagnosis, regimen intensity, graft source (BM, PBSC), disease risk index (low/intermediate, high/very high), CIBMTR risk (low, intermediate, high), HCT-CI (0-2, &gt;=3), CMV status, year of transplantation (2008-2012, 2013-2015, 2016-2017). The following variables were evaluated as time-dependent covariates in Cox models: all-grade cGVHD, moderate-severe cGVHD, severe cGVHD, grade 2-4 aGVHD, grade 3-4 aGVHD. Variables were selected if p values were less than 0.05. Developing grade 3-4aGVHD and severe chronic GVHD were both associated with worse OS, DFS and TRM (table 2). Both aGVHD and cGVHD were not significant factors for relapse. Our analysis reveals that compared to MUD, haplo transplant results in significantly lower incidence of moderate-severe chronic GVHD, faster cGVHD onset, different organ distribution and a higher chance of coming off immunosuppression. This data, added to prior publications from our center and others showing similar OS and DFS between MUD and haplo, enforces the notion that haplo transplant with PTCY is at least equivalent to MUD transplant. An ongoing BMTCTN 1702(CTRL-ALT-D) study will help answer assess this in a prospective fashion. figure 1: Chronic GVHD patients who are Immunosuppression free at 2 years Table 1: Organ Distribution of Chronic GVHD by Donor Type Disclosures No relevant conflicts of interest to declare.

Evaluation of treatment response in oral chronic graft-versus-host patients by power doppler ultrasound: a prospective study.

To date, imaging and non-invasive examination methods for evaluating the oral tissue of patients who with oral chronic graft-versus-host disease (GVHD) are still lacking. Herein, we assessed the ultrasonography imaging characteristics of chronic GVHD patients' buccal soft tissue and evaluated the response to treatment using gray-scale and power Doppler (PD) ultrasound. The overall objective of the study was to determine the potential of ultrasonography to provide an early and objective indication of a therapeutic response to treatment intervention in oral chronic GVHD. Buccal mucosa in 21 patients with clinically diagnosis of oral chronic GVHD were assessed before and after 14 day treatment between 2016 and 2018. Ultrasonography assessment included thickness and echogenicity evaluation, and PD. Echogenicity and PD were measured and scored according to a semi-quantitative method. Ultrasonography parameters were compared with clinical activity assessments of disease activity and patient-reported measures. Following 14 day therapy, a significant decrease in PD scores and patient-reported measures was observed (p < 0.01), and clinical assessment scores also decreased (p < 0.05). Changes from baseline PD scores correlated significantly with patient-reported measures (r = 0.85, p < 0.01). Changes in PD scores correlated moderately with the changes in the clinical assessments from baseline (r = 0.46, p < 0.05). A significant decrease in PD scores was observed in the buccal soft tissue of patients that responded clinically to the treatment. A significant decrease in PD scores was also observed in patients that were failed to show clinical improvement (p < 0.05). Ultrasonography is a novel and feasible imaging technique for measurement of the response of oral chronic GVHD to therapy. Ultrasonography yields additional information about buccal mucosa and is a complementaty to clinical examination.

Corneal higher-order aberrations in eyes with chronic ocular graft-versus-host disease

PurposeChronic ocular graft-versus-host disease (GVHD) is a long-term complication after hematopoietic stem cell transplantation (HSCT) and leads to irreversible visual morbidity due to severe ocular surface impairments including visual disfunction. However, knowledge about the optical function in chronic ocular GVHD is limited because it is difficult to assess quantitative optical function objectively. The development of anterior segment optical coherence tomography has allowed objective quantification of optical function by evaluating corneal higher-order aberrations (HOAs). Therefore, we applied this quantification in chronic ocular GVHD patients and verified the correlation between corneal HOAs and visual acuity. MethodsWe retrospectively reviewed chronic ocular GVHD patients and the recipients after HSCT. Then, analyzed the relationship between visual function and the severity of chronic ocular GVHD. ResultsThe eyes of patients with chronic ocular GVHD had higher corneal HOAs than those of non-GVHD patients (HOAs; 0.481 ± 0.306 vs 0.254 ± 0.084, and 0.917 ± 0.609 vs 0.529 ± 0.130. P < 0.001, and 0.002. 4-mm and 6-mm diameters respectively. Corneal HOAs were correlated with the severity of chronic ocular GVHD (r = 0.436. P < 0.001). Moreover, corneal HOAs were correlated with visual acuity, especially in eyes with severe chronic ocular GVHD cases (HOAs; 4-mm r = 0.636. P = 0.036. Total 6-mm r = 0.871. P =<0.001). ConclusionsWe succeed to assess the objective value in the optical function of the chronic ocular GVHD. Quantification of corneal HOAs could be an objective evaluation to assess optical function in eyes with chronic ocular GVHD.

PB2349 EXTRACORPOREAL PHOTOPHERESIS FOR PEDIATRIC PATIENTS WITH GRAFT‐VS‐HOST DISEASE AFTER HAEMATOPOIETIC STEM CELL TRANSPLANTATION: AN AUSTRALIAN EXPERIENCE

Background:Graft‐versus‐host disease (GVHD) remains a major cause of morbidity and mortality following pediatric allogeneic hematopoietic stem cell transplant (HSCT). Extracorporeal photopheresis (ECP) is a cellular immuno‐modulatory therapy licensed for the treatment of steroid‐dependent or refractory GVHD. ECP has been shown to be effective in the treatment of GVHD in the adult population, however there is little data in the pediatric setting. Here we present our Australian experience in paediatric patients with GVHD.Aims:To assess the outcome and feasibility of ECP as a treatment modality for GVHD in the pediatric allograft patients in Australia.Methods:A retrospective case note analysis of all patients receiving ECP for the treatment of GVHD between August 2010 and December 2018 at the Royal Children's Hospital and Peter MacCallum Cancer Centre, Victoria.Results:14 patients were identified, with a median age of 4.4 years (range 0.5‐14.8). Demographic and transplant characteristics are summarised in Table 1. ECP was used to treat both acute (aGVHD, n = 7) and chronic (cGVHD, n = 8) GVHD. One patient required two treatment episodes for acute and subsequently chronic GVHD. All patients were refractory to prior immunosuppressive therapy, with a median of 3 agents used (range 2‐5). Median steroid dose was 0.8 mg/kg/day methylprednisolone equivalent (range 0‐2). An overall response was obtained in 6 of 7 (86%) acute and 6 of 8 (75%) chronic GVHD patients. Overall survival was 79% (11 of 14 patients).Of those treated for aGVHD varying from grade II – IV, 86% (n = 6) showed a partial response or better, with 43% (n = 3) achieving a complete response. Median steroid dose was reduced by 94% from 1.8 mg/kg/day methylprednisolone equivalent to 0.1 mg/kg/day from beginning to end of ECP. ECP duration was a median of 1.9 months (range 1.4‐5.7), with a median of 16 treatments (range 12‐25).The majority of cGVHD patients had extensive disease (n = 7, 88%), with 75% (n = 6) achieving at least a partial response, with a complete response in 37.5% (n = 3). Median steroid dose was reduced by 88% from 0.18 mg/kg/day methylprednisolone equivalent to 0.02 mg/kg/day from beginning to end of ECP. ECP was used for a median period of 7.1 months (range 1.9‐39.1) with a median of 25 treatments (range 7‐61).Catheter‐related sepsis was the most common reason for premature discontinuation of ECP in our cohort, occurring in 6 patients (43%). Other noted complications included haemodynamic instability requiring admission, occurring in 3 patients (21%). This caused discontinuation of ECP in one patient weighing 7.5 kg. Of the 3 patients who died, two had grade IV aGVHD with progressive disease post‐ECP, and one with refractory extensive cGVHD. The causes of death were sepsis (n = 2) and relapsed primary malignancy (n = 1).Summary/Conclusion:This is the first report of ECP therapy in Australia for pediatric patients with GVHD. Our results demonstrate that ECP is an effective and feasible treatment modality for both acute and chronic GVHD post‐HSCT. In our cohort, ECP allowed for tapering of corticosteroids, which has been shown to be associated with improved survival. Although ECP was well tolerated overall, specific consideration should be given when used in the pediatric population, especially with regard to the risk of haemodynamic instability, the use of blood prime of the circuit and catheter‐related sepsis.image

The Effect of Azithromycin on Relapse in Patients with Moderate-Severe Chronic Graft Versus Host Disease (CGVHD)

BACKGROUND A recent U.S. Food and Drug Administration (FDA) safety communication (Aug 2018) warned prescribers of the risk of relapse in patients receiving azithromycin as prophylaxis for bronchiolitis obliterans syndrome (BOS) following hematopoietic cell transplant (HCT). However, the FDA warning was based upon a single multicenter trial, in which patients were randomized to receive azithromycin for 2 years, starting at the time of conditioning. We now examine relapse rates in a cohort of patients treated with azithromycin for management of moderate-severe CGVHD. PATIENT POPULATION A retrospective review of our HCT database (2010-2017) identified 239 patients (median age 55 years, range 4-72) with moderate-severe CGVHD following an allogeneic HCT for a primary hematologic malignancy. NIH consensus criteria (2015) were used for CGVHD grading. Patients were divided into 2 cohorts, a) those receiving an extended course of azithromycin (≥ 14 days) for CGVHD management (cohort 1, n=86) and b) those who did not (cohort 2, n=153). Patients in cohort 2 either did not receive any azithromycin (n=122) or had received an abbreviated ( RESULTS Decreased rates of relapse and improved survival were noted for patients treated with azithromycin for CGVHD. At 2 years, the cumulative incidence of relapse was 2% (95% CI:1-9%) for patients in cohort 1 vs 16% (95% CI: 11-23%) in cohort 2, p=0.001. Overall survival (2-year OS) in cohort 1 was 93% (95%CI: 88-99%) vs 78% (95% CI:72-85%) for cohort 2, p=0.003. Overall, 7 of 86 (8.1%) CGVHD patients treated with an extended course of azithromycin (cohort 1) have relapsed, the median time to relapse 876 days (range 379-1303) post-HCT. In comparison, 28 of 153 (18.3%) in cohort 2 have relapsed, a median 371 days (range 98-1252) post-HCT. CONCLUSION The use of azithromycin for the management of moderate to severe CGVHD was not associated with an increased risk of relapse in patients undergoing HCT for a hematologic malignancy. Azithromycin therapy for patients with CGVHD should not be contra-indicated in this patient population.

C5aR1 regulates T follicular helper differentiation and chronic graft-versus-host disease bronchiolitis obliterans.

CD4+ follicular helper T (Tfh) cells are specialized providers of T cell help to B cells and can function as pathogenic mediators of murine antibody-dependent chronic graft-versus-host disease (GvHD). Using a parent→F1 model of lupus-like chronic GvHD, in which Tfh cell and germinal center (GC) B cell differentiation occurs over 14 days, we demonstrate that absence of CD4+ T cell-expressed C5a receptor 1 (C5ar1) or pharmacological C5aR1 blockade abrogated generation/expansion of Tfh cells, GC B cells, and autoantibodies. In a Tfh cell-dependent model of chronic GvHD manifested by bronchiolitis obliterans syndrome (BOS), C5aR1 antagonism initiated in mice with established disease ameliorated BOS and abolished the associated differentiation of Tfh and GC B cells. Guided by RNA-sequencing data, mechanistic studies performed using murine and human T cells showed that C5aR1 signaling amplifies IL-6-dependent expression of the transcription factor c-MAF and the cytokine IL-21 via phosphorylating phosphokinase B (AKT) and activating the mammalian target of rapamycin (mTOR). In addition to linking C5aR1-initiated signaling to Tfh cell differentiation, our findings suggest that C5aR1 may be a useful therapeutic target for prevention and/or treatment of individuals with Tfh cell-dependent diseases, including those chronic GvHD patients who have anti-host reactive antibodies.

SYK inhibitor entospletinib prevents ocular and skin GVHD in mice.

Graft-versus-host disease (GVHD) is a major complication of hematopoietic stem cell transplantation (HCT). The tyrosine kinase SYK contributes to both acute and chronic GVHD development, making it an attractive target for GVHD prevention. Entospletinib (ENTO) is a second-generation highly selective SYK inhibitor with a high safety profile. Potential utility of ENTO as GVHD prophylaxis in patients was examined using a preclinical mouse model of eye and skin GVHD and ENTO-compounded chow. We found that early SYK inhibition improved blood immune cell reconstitution in GVHD mice and prolonged survival, with 60% of mice surviving to day +120 compared with 10% of mice treated with placebo. Compared with mice receiving placebo, mice receiving ENTO had dramatic improvements in clinical eye scores, alopecia scores, and skin scores. Infiltrating SYK+ cells expressing B220 or F4/80, resembling SYK+ cells found in lichenoid skin lesions of chronic GVHD patients, were abundant in the skin of placebo mice but were rare in ENTO-treated mice. Thus, ENTO given early after HCT safely prevented GVHD.

Serum Vitamin A Levels May Affect the Severity of Ocular Graft-versus-Host Disease.

Allogeneic hematopoietic stem cell transplantation (HSCT) is a well-established therapeutic option for a range of inherited and acquired hematological disorders. However, graft-versus-host disease (GVHD) remains the leading cause of non-relapse mortality in allogeneic HSCT recipients. Ocular involvement occurs in up to 80% of chronic GVHD patients. In our cases, the diagnosis of vitamin A deficiency was suspected for GVHD patients. Serum vitamin A measurements were conducted to confirm clinical suspicions. Our study revealed significant decrease in serum levels of vitamin A in chronic liver GVHD patients. Although there have been many studies evaluating ocular manifestations in patients with GVHD, the present study is, to our knowledge, the first to study the relationship between vitamin A and ocular manifestations of GVHD in humans. Our data suggest that vitamin A deficiency affects the severity of ocular GVHD in adults.