Graft-versus-host Disease Therapy Research Articles

Novel Concept of CD4-Mediated Activation of Regulatory T Cells for the Treatment of Graft-Versus-Host Disease.

Allogeneic hematopoietic stem cell transplantation is the only curative treatment option for several hematological malignancies and immune deficiency syndromes. Nevertheless, the development of a graft-versus-host disease (GvHD) after transplantation is a high risk and a severe complication with high morbidity and mortality causing therapeutic challenges. Current pharmacological therapies of GvHD lead to generalized immunosuppression followed by severe adverse side effects including infections and relapse of leukemia. Several novel cell-based immunomodulatory strategies for treatment or prevention of GvHD have been developed. Herein, thymus-derived regulatory T cells (tTreg), essential for the maintenance of peripheral immunologic tolerance, are in the focus of investigation. However, due to the limited number of tTreg in the peripheral blood, a complex, time- and cost-intensive in vitro expansion protocol is necessary for the production of an efficient cellular therapeutic. We demonstrated that activation of tTreg using the CD4-binding human immunodeficiency virus-1 protein gp120 leads to a substantially increased suppressor activity of tTreg without the need for additional expansion. Gp120-activated tTreg prevent GvHD development in a preclinical humanized mouse model. In addition, gp120 is not only effective in prevention but also in therapy of GvHD by suppressing all clinical symptoms and improving survival of treated mice. These data indicate that tTreg activation by gp120 is a feasible and potent strategy for significant functional improvement of tTreg as cellular therapeutic for GvHD treatment without the need of complicated, time-intensive, and expensive in vitro expansion of isolated tTreg.

Healthcare Costs Of Patients With Acute And Chronic Graft-Versus-Host Disease Following Allogeneic Haematopoietic Stem Cell Transplantation In Belgium: A Retrospective Data Collection And Analysis

Graft-versus-host disease (GvHD) presents a major challenge to successful allogeneic stem cell transplantation (aSCT). Extracorporeal photopheresis (ECP) is a promising alternative to standard immunosuppressive therapies but it was not available at the participating study centre in Belgium. A retrospective analysis was undertaken of resource use and treatment costs with available therapies in patients who developed steroid-refractory or steroid-dependent acute (aGvHD) or chronic GvHD (cGvHD) following aSCT. Data were collected on number, duration and cost of hospitalisations, GvHD-related diagnostic procedures, and treatment for the management of symptoms and complications of GvHD. A hypothetical date was identified (the index date; ID) at which clinicians would have referred patients to ECP had it been available. Costs were analysed prior to the potential referral for ECP and compared with those after referral. The study group comprised 26 patients with aGvHD (n=17) or cGvHD (n=9), all eligible for ECP treatment had it been available. The costs of GvHD management at the centre were primarily driven by high inpatient hospitalisation costs. Average monthly inpatient cost was €2,687 per patient prior to the ID and €2,689 between the ID and the end of the study. Average monthly outpatient cost was €753 per patient prior to the ID and €542 between the ID and end of the analysis. This analysis, undertaken in a small number of patients, suggests that the management of patients with GvHD following aSCT is associated with high healthcare burden in Belgium, primarily related to hospitalisations. A significant unmet need remains for effective GvHD therapies and options such as ECP should be considered. Accessibility to ECP is limited in Belgium and not reimbursed. A similar retrospective analysis is planned to confirm potential changes in healthcare utilisation and costs with ECP treatment.

Pilot study of lithium to restore intestinal barrier function in severe graft-versus-host disease.

Severe intestinal graft-vs-host disease (GVHD) after allogeneic hematopoietic cell transplantation (HCT) causes mucosal ulceration and induces innate and adaptive immune responses that amplify and perpetuate GVHD and the associated barrier dysfunction. Pharmacological agents to target mucosal barrier dysfunction in GVHD are needed. We hypothesized that induction of Wnt signaling by lithium, an inhibitor of glycogen synthase kinase (GSK3), would potentiate intestinal crypt proliferation and mucosal repair and that inhibition of GSK3 in inflammatory cells would attenuate the deregulated inflammatory response to mucosal injury. We conducted an observational pilot study to provide data for the potential design of a randomized study of lithium. Twenty patients with steroid refractory intestinal GVHD meeting enrollment criteria were given oral lithium carbonate. GVHD was otherwise treated per current practice, including 2 mg/kg per day of prednisone equivalent. Seventeen patients had extensive mucosal denudation (extreme endoscopic grade 3) in the duodenum or colon. We observed that 8 of 12 patients (67%) had a complete remission (CR) of GVHD and survived more than 1 year (median 5 years) when lithium administration was started promptly within 3 days of endoscopic diagnosis of denuded mucosa. When lithium was started promptly and less than 7 days from salvage therapy for refractory GVHD, 8 of 10 patients (80%) had a CR and survived more than 1 year. In perspective, a review of 1447 consecutive adult HCT patients in the preceding 6 years at our cancer center showed 0% one-year survival in 27 patients with stage 3–4 intestinal GVHD and grade 3 endoscopic appearance in the duodenum or colon. Toxicities included fatigue, somnolence, confusion or blunted affect in 50% of the patients. The favorable outcomes in patients who received prompt lithium therapy appear to support the future conduct of a randomized study of lithium for management of severe GVHD with extensive mucosal injury.Trial Registration: ClinicalTrials.gov NCT00408681

Graft Versus Host Disease Following Intestine Transplantation

Introduction: Graft versus host disease (GVHD) remains one of the most feared medical complications following intestine transplantation (ITx). Few contemporary studies have evaluated the incidence and outcomes of GVHD following ITx. Methods: All ITx performed at our institution from 2003 through 2016 were included in this study and evaluated with the use of a prospectively maintained database. The incidence, associated clinical factors, treatment and outcomes were evaluated for all patients with GVHD. Results: There were 234 transplants performed in 228 patients during this period, including 133 isolated intestine, 59 liver-intestine, 35 multivisceral and 7 modified multivisceral transplants. There were 13 (5.6%) cases of GVHD (6 adults and 7 pediatric) with a median presentation of 77 days (range 14–373) following transplantation. 8 patients received multivisceral or modified multivisceral grafts, 4 patients received isolated intestine grafts, and 1 liver-intestine. 8 patients had native splenectomy at time of transplant and 3 patients had a known immunodeficiency. The most common presentation was a rash (n=8), other clinical manifestations included native GI involvement (n=7), pulmonary involvement (n=3), and bone marrow involvement (n=3). Chimerism data was available for 8 patients and was positive in 7. Immunosuppression was augmented in all cases and median number of treatments/patient was 2 (range 1–4). Treatments included steroids (n=13), thymoglobulin (n=6), alemtuzumab (n=2), extracorporeal photopheresis (n=3), and bone marrow transplant (n=1). The majority of cases 9/13 (69.3%) were fatal despite aggressive treatment. The 5-year survival for patients with GVHD was 30.7% versus 70.5% for patients without GVHD (p=0.001). Statistically significant risk factors for GVHD included multivisceral graft and native splenectomy. Only 1 (7.6%) patient with GVHD had acute rejection compared to 17.7% in the patients without GVHD (p=0.001). Conclusions: Despite modern immunosuppression regimens and advances in treatment, GVHD carries a high mortality. New therapies for GVHD are needed as well as aggressive surveillance protocols in multivisceral graft recipients and patients with a history of splenectomy.

Extracorporeal Photopheresis Is Effective in Treating Graft-Versus-Host Disease: A Retrospective Analysis

Introduction: Graft-versus-host disease (GVHD) remains the most common cause of morbidity and transplant-related mortality after allogeneic hematopoietic stem cell transplantation, despite significant advances in prophylaxis and treatment. Extracorporeal photopheresis (ECP) is an immunomodulatory therapy for which cutaneous T cell lymphoma is currently the only FDA-approved indication; it is, however, increasingly used as a second-line therapy for acute and chronic GVHD patients who are steroid-refractory or -dependent. Evidence suggests overall response rates of 60-80%, with better response rates among patients with cutaneous manifestations. This retrospective analysis reports our experience using ECP to treat adults with acute and chronic GVHD over a 5-year period.Methods: We identified 67 patients (age 21-69, 70% males) who underwent ECP therapy for GVHD between November 1, 2010 and June 2, 2016. Eleven patients were excluded based on exclusion criteria of fewer than 8 procedures, any part of ECP course performed at an outside institution, and inadequate documentation regarding GVHD response. Among the remaining 56 patients, 6 underwent more than one course of ECP, resulting in a total of 62 courses of ECP included in final analysis. Charts were reviewed for each of these 62 courses to obtain relevant demographic and transplant-related data, type of GVHD, and organs involved. Response was assessed separately for each involved organ using strict response criteria and was censored on the date of last ECP procedure. Hematology notes were reviewed for noted worsening or improvement of GVHD, and a response was counted only if it was maintained throughout the remainder of the ECP course, including the date of last procedure.Results: Results are summarized in Table 1. Tapering of immunosuppressive therapy by end of ECP course, defined as steroid tapering by at least 50% from baseline or steroid withdrawal and tapering of other immunosuppressive therapy, was successful in 43 out of 62 (69%) ECP courses. Overall response rate, defined as complete or partial response, was highest for skin GVHD (73%) and lowest for lung GVHD (27%). However, 6 out of 11 (54%) patients with lung involvement experienced no progression of disease, which may be considered a successful response in these difficult-to-manage patients. Twenty-two out of 62 courses did have a new immunosuppressive agent, such as mycophenylate mofetil, tacrolimus, or rituximab, introduced at the start of or during the ECP course, and 11 of these 22 courses achieved a response that may not reflect therapeutic effect of ECP alone. Four patients developed new progressive liver or lung involvement by GVHD even as other involved organs in these patients, such as skin, showed complete response.Conclusion: Response rates to ECP at our institution are similar to those reported in the literature; it is a useful therapeutic option in patients with acute or chronic GVHD, particularly those with skin involvement. ECP allows successful tapering or withdrawal of immunosuppressive therapy in the majority of patients, even in those who are steroid-refractory or steroid-dependent. [Display omitted] DisclosuresSarode:CSL Behring: Consultancy, Honoraria.

Regional Intra-Arterial Steroid Treatment in 113 Patients with Steroid Resistant or Dependent Graft-Versus-Host Disease

Introduction: Graft-versus-host disease (GVHD) is a major complication of allogeneic bone marrow transplantation (BMT), resulting in death in the majority of steroid-resistant patients.In the past 15 years, we revolutionized the use of interventional radiology procedures in the field of stem cell transplantation. This study was aimed to assess the efficacy of regional intra-arterial steroid (IAS) treatment in the largest published cohort of patients with resistant/dependent hepatic and/or gastrointestinal (GI) GVHD. In total, 113 patients with steroid resistant or dependent grade 3-4 hepatic (n = 21), gastrointestinal (GI) (n = 62) GVHD or both (n = 30) were given intra-arterial treatment.Patients and methods: Patients with liver GVHD received IAS in hepatic artery and patients with gastrointestinal GVHD received IAS in the superior and inferior mesenteric as well as the internal iliac arteries. Patients with pronounced upper GI symptoms also received IAS to the gastroduodenal artery. In total 148 procedures were carried out (range 1-3 per patient).Results: Partial responses were observed in 33 out of 51 (65%) patients with hepatic GVHD, out of which (55%) had complete response. Median time to complete response was 45 days (range - 5 to 300 days).For GI GVHD complete responses were observed in 69 out of 92 (75%) and partial responses were observed in 76 out of 92 (83%). The median time to complete response was 20 days (range - 3 to 200 days ).As this is the largest published cohort of regional IAS therapy for GVHD, multivariate and univariate analysis was done in order to identify the patients with highest chance of response.Conclusions: Regional treatment of severe GVHD with IAS treatment is effective and safe. GI treatment is more effective than intrahepatic treatment. Early administration of isolated intra-arterial therapy in high-risk patients may further improve the outcome and reduce untoward effects of prolonged systemic immunosuppressive treatment. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

An Early Biomarker Algorithm Predicts Lethal Graft-Versus-Host Disease and Survival after Allogeneic Hematopoietic Cell Transplantation

No laboratory test can predict non-relapse mortality (NRM) after hematopoietic cellular transplantation (HCT) prior to the onset graft-versus-host disease (GVHD). Recently, we have shown that a signature of three GVHD plasma biomarkers (TNFR1, ST2, and REG3α) can predict response to GVHD therapy and NRM at the onset of clinical GVHD (Levine, Lancet Haem, 2015). Our goal in the current study was to identify a blood biomarker signature that could predict lethal GVHD and six-month NRM well in advance of the onset of GVHD symptoms. Patient samples on day +7 after HCT were obtained from 1,287 patients from 11 HCT centers in the Mount Sinai Acute GVHD International Consortium (MAGIC). Samples from two large centers (n = 929) were combined and randomly assigned to a training set (n = 620) and test set (n = 309). 358 patients from nine others centers constituted an independent validation set. The overall cumulative incidences of 6-month NRM were 11%, 12%, and 13% for the training, test, and validation sets respectively. The incidence of lethal GVHD, defined as death without preceding relapse while under steroid treatment for acute GVHD, were 18%, 24%, and 14% in the same groups, respectively. The median day of GVHD onset was 28 days in the training set and 29 days in the test and validation sets. We measured four GVHD related biomarkers [ST2, REG3α, TNFR1, and IL2Rα] in all samples and used the training set alone to develop competing risks regression models that used all 13 possible combinations of one to four biomarkers to predict 6-month NRM. The best algorithm, which we rigorously confirmed through Monte Carlo cross-validation of 75 different combinations of training sets, included ST2 and REG3α. No combination of one, three, or four biomarkers was superior to the combination of these two biomarkers. The day 7 algorithm identified high risk (HR) and low risk (LR) groups with 6-month NRMs of 28% and 7%, respectively (p<0.001) (Fig 1A). The relapse rates did not differ between risk groups so that overall survival (OS) was 60% for HR and 84% for LR (p<0.001) (Fig 1B). When applied to the test set (Fig 1C/D), the algorithm identified 54/309 (17%) of the patients as HR with an NRM of 33% vs 7% for LR patients (p<0.001) and 6-month OS of 57% and 81% for HR and LR patients, respectively (p<0.001). In the independent validation set (Fig 1 E/F), the algorithm identified 72/358 (20%) of the patients as HR with an NRM of 26% vs 10% for LR patients (p<0.001) and OS of 68% and 85% for HR and LR patients, respectively (p<0.001). High risk patients were three times more likely to die from GVHD than LR patients in each cohort (p<0.001) (Fig 2). The GI tract is the GVHD target organ that is most resistant to treatment and represents a major cause of NRM, and we observed twice as much severe GI GVHD (stage 3 or 4) in HR patients as in LR patients (p<0.001, data not shown). The algorithm successfully separated HR and LR strata for 6 month NRM in several groups with differing risks for GVHD and NRM, including donor type, degree. of HLA-match, age group, and conditioning regimen intensity (Fig 3).In conclusion, we have developed a blood biomarker algorithm that predicts the development of lethal GVHD seven days after HCT, which performed successfully in large multicenter validation sets. The GVH reaction is already in progress by day +7, even though clinical symptoms may not occur until days or weeks later. We speculate that the blood biomarker concentrations at this early time point reflect subclinical GI pathology, a notion that is reinforced by the fact that ST2 and REG3α, the two biomarkers in the algorithm, are closely associated with GI GVHD. The algorithm identified HR and LR strata in several patient groups with different overall risk for lethal GVHD (donor, HLA match, conditioning regimen intensity, age). This day +7 algorithm should prove useful in clinical BMT research by identifying patients at high risk for lethal GVHD who might benefit from aggressive preemptive treatment strategies. [Display omitted] [Display omitted] [Display omitted] DisclosuresChen:Novartis: Research Funding; Incyte Corporation: Consultancy, Membership on an entity’s Board of Directors or advisory committees, Research Funding. Jagasia:Therakos: Consultancy. Kitko:Therakos: Honoraria, Speakers Bureau. Kroeger:Novartis: Honoraria, Research Funding. Levine:Viracor: Patents & Royalties: GVHD biomarkers patent. Ferrara:Viracor: Patents & Royalties: GVHD biomarkers patent.

Pentraxin 3 plasma levels at graft-versus-host disease onset predict disease severity and response to therapy in children given haematopoietic stem cell transplantation.

Acute Graft-versus-Host Disease (GvHD) remains a major complication of allogeneic haematopoietic stem cell transplantation, with a significant proportion of patients failing to respond to first-line systemic corticosteroids. Reliable biomarkers predicting disease severity and response to treatment are warranted to improve its management. Thus, we sought to determine whether pentraxin 3 (PTX3), an acute-phase protein produced locally at the site of inflammation, could represent a novel acute GvHD biomarker. Using a murine model of the disease, we found increased PTX3 plasma levels after irradiation and at GvHD onset. Similarly, plasma PTX3 was enhanced in 115 pediatric patients on day of transplantation, likely due to conditioning, and at GvHD onset in patients experiencing clinical symptoms of the disease. PTX3 was also found increased in skin and colon biopsies from patients with active disease. Furthermore, PTX3 plasma levels at GvHD onset were predictive of disease outcome since they resulted significantly higher in both severe and therapy-unresponsive patients. Multiple injections of rhPTX3 in the murine model of GvHD did not influence the disease course. Taken together, our results indicate that PTX3 constitutes a biomarker of GvHD severity and therapy response useful to tailor treatment intensity according to early risk-stratification of GvHD patients.

The Potential of Mesenchymal Stromal Cells as Treatment for Severe Steroid-Refractory Acute Graft-Versus-Host Disease: A Critical Review of the Literature.

Acute graft-versus-host disease (GvHD) is a major complication after allogeneic hematopoietic stem cell transplantation which causes high morbidity and mortality among patients who do not respond to steroid treatment. Mesenchymal stromal cells (MSCs) have immune modulatory abilities and earned their place in the treatment of GvHD after a pediatric patient remarkably recovered from steroid-refractory acute GvHD with MSC salvage therapy. Large, prospective clinical trials evaluating the potency of MSCs have however not been published. To evaluate the therapeutic potential of MSCs in the treatment of steroid-refractory acute GvHD, we conducted a systematic literature search. We included all studies that focused on MSC treatment of adult allogeneic hematopoietic stem cell transplantation recipients with grades III to IV steroid-refractory acute GvHD and were transparent about their methods and patient selection criteria. From a total of 255 articles, 9 articles met the quality criteria for this study. The proportion of patients achieving complete resolution of all symptoms (complete response, CR) varied between 8% and 83%. Four of the 9 studies reported CR rates above 50%. The GvHD grade at the time of treatment was identified as a predictor of clinical response. Interestingly, complete response but not partial response to MSCs was associated with overall survival. No serious side effects of MSC therapy were reported. MSC treatment does improve the outcome in steroid-refractory acute GvHD patients but well-designed, prospective randomized clinical trials are needed to confirm the potential of MSCs as salvage therapy for steroid-refractory GvHD and to identify those patients that will benefit most.

Acute and chronic Graft-versus-host disease after hematopoietic stem cell transplantation.

graft-versus-host disease (GVHD) is one of the main complications of hematopoietic stem cell transplantation, affecting about 50% to 80% of the patients. Acute GVHD and its clinical manifestations are discussed in this article, as well as the new NIH criteria for the diagnosis and classification of chronic GVHD. Therapy for both chronic and acute GVHD is an important field of discussion, as there is no proven superiority for the majority of therapies used after primary treatment has failed. Hence, this review is meant to be a useful consultation tool for hematologists dealing with this complex transplantation procedure complication.

Development of Regulatory T Cells Mediated by NF-κB and Its Role in GVHD -Review

Graft versus host disease (GVHD) is the major complication of allogenic hematopoietic stem cell transplantation (allo-HSCT), and is a mainly responsible result for the non-recurrence-related mortality of long-term survived patient after transplantation. Studies indicated that regulatory T (Treg) cells can inhibit early-GVHD. Since the transcriptional factor NF-κB has been implicated in the regulation of Treg cell proliferation and activation, it becomes a potential target of GVHD therapy. Thus, in this review the function and signaling pathway of NF-κB, as well as the relationship between GVHD and NF-κB, are discussed and summarized.

Preclinical models of acute and chronic graft-versus-host disease: how predictive are they for a successful clinical translation?

AbstractDespite major advances in recent years, graft-versus-host disease (GVHD) remains a major life-threatening complication of allogeneic hematopoietic cell transplantation (allo-HCT). To improve our therapeutic armory against GVHD, preclinical evidence is most frequently generated in mouse and large animal models of GVHD. However, because every model has shortcomings, it is important to understand how predictive the different models are and why certain findings in these models could not be translated into the clinic. Weaknesses of the animal GVHD models include the irradiation only-based conditioning regimen, the homogenous donor/recipient genetics in mice, canine or non-human primates (NHP), anatomic site of T cells used for transfer in mice, the homogenous microbial environment in mice housed under specific pathogen-free conditions, and the lack of pharmacologic GVHD prevention in control groups. Despite these major differences toward clinical allo-HCT, findings generated in animal models of GVHD have led to the current gold standards for GVHD prophylaxis and therapy. The homogenous nature of the preclinical models allows for reproducibility, which is key for the characterization of the role of a new cytokine, chemokine, transcription factor, microRNA, kinase, or immune cell population in the context of GVHD. Therefore, when carefully balancing reasons to apply small and large animal models, it becomes evident that they are valuable tools to generate preclinical hypotheses, which then have to be rigorously evaluated in the clinical setting. In this study, we discuss several clinical approaches that were motivated by preclinical evidence, novel NHP models and their advantages, and highlight the recent advances in understanding the pathophysiology of GVHD.

Concise Review: Mechanisms Behind Apoptotic Cell-Based Therapies Against Transplant Rejection and Graft versus Host Disease.

The main limitations to the success of transplantation are the antigraft response developed by the recipient immune system, and the adverse side effects of chronic immunosuppression. Graft-versus-host disease (GVHD) triggered by donor-derived T lymphocytes against the recipient tissues is another serious obstacle in the field of hematopoietic stem cell transplantation. Several laboratories have tested the possibility of promoting antigen (Ag)-specific tolerance for therapy of graft rejection, GVHD, and autoimmune disorders, by developing methodologies that mimic the mechanisms by which the immune system maintains peripheral tolerance in the steady state. It has been long recognized that the silent clearance of cells undergoing apoptosis exerts potent immune-regulatory effects and provides apoptotic cell-derived Ags to those Ag-presenting cells (APCs) that internalize them, in particular macrophages and dendritic cells. Therefore, in situ-targeting of recipient APCs by systemic administration of leukocytes in early apoptosis and bearing donor Ags represents a relatively simple approach to control the antidonor response against allografts. Here, we review the mechanisms by which apoptotic cells are silently cleared by phagocytes, and how such phenomenon leads to down-regulation of the innate and adaptive immunity. We discuss the evolution of apoptotic cell-based therapies from murine models of organ/tissue transplantation and GVHD, to clinical trials. We make emphasis on potential limitations and areas of concern of apoptotic cell-based therapies, and on how other immune-suppressive therapies used in the clinics or tested experimentally likely also function through the silent clearance of apoptotic cells by the immune system. Stem Cells 2016;34:1142-1150.

Human Mesenchymal Stem Cell Therapy for Acute Graft Versus Host Disease

Acute graft versus host disease (GVHD) is the most critical complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The understanding of major histocompatibility complex (MHC) and the development of acute GVHD prophylaxis have contributed to decreasing the incidence of severe acute GVHD. However, these progresses expand the chance of receiving allo-HSCT from human leukocyte antigen (HLA) mismatched donor. In addition, the expanding of indication for allo-HSCT to elderly patients or patients with organ dysfunction by the pervasiveness of reduced-intensity conditioning is associated with increased risk of acute GVHD. Unexpectedly, severe refractory acute GVHD can occur even in allo-HSCT from HLA matched sibling donor. The first line therapy for severe acute GVHD is corticosteroid, but the second line therapy has not been established and the prognosis of steroid-resistant acute GVHD remains poor. Recently, the efficacy of human bone marrow mesenchymal stem cell (MSC) therapy for steroid-resistant acute GVHD has been consistently reported. MSCs are approved as a cell therapy drug for steroid-resistant acute GVHD in some countries. We here review the history and the future of MSC therapy for acute GVHD.

A fast and fatal course of bronchiectasis: an unusual rare expression of chronic graft versus host disease. A case report.

Introduction. We report a case of a patient with acute myeloid leukaemia whose treatment with bone marrow transplantation (BMT) was followed by chronic graft versus host disease (GVHD) with lung involvement and bronchiectasis. This report illustrates an unusual course of a fast progression of the bronchiectasis due to BMT.Case description. A 33-year-old female was diagnosed with acute myeloid leukaemia. An allogeneic BMT was performed. One month after the transplantation, acute GVHD with skin involvement occurred. Treatment with prednisolone and mycophenolate mofetil (MMF) has been started. Nine months later, the patient was examined by a pulmonologist due to progressive dyspnoea. A pulmonary computed tomography (CT) scan showed normal parenchyma of the lungs and no changes to the bronchi. A CT scan performed 7 months later revealed bronchiectasis for the first time. No clinical response was associated with the treatment and the patient’s respiratory status progressively deteriorated. During the final hospitalization, a CT scan performed 1 year later revealed huge cystic bronchiectasis in both lungs. Despite the prophylaxis and treatment of GVHD and aggressive antimicrobial therapy, the patient died one year after the diagnosis of bronchiectasis.Conclusions. This case demonstrates that a fast and fatal course of bronchiectasis, that occurs after BMT, should always be considered as a possible manifestation of chronic graft versus host disease (cGVHD) following allogeneic BMT.

Treatment of acute graft-versus-host disease.

Methylprednisolone administered at a dose of 2 mg/kg is a standard first-line systemic therapy for grade II to IV acute graft-versus-host disease (GVHD). Lower dose methylprednisolone or prednisone, at doses of 0.5-1.0 mg/kg, is also accepted as a first-line therapy for mild acute GVHD. Response rates of grade II to IV acute GVHD to systemic corticosteroid therapy in Japanese patients range from 40-70%, depending on the donors. No improvement within 5 days after first-line therapy or progression within 3 days after first-line therapy could make patients eligible for second-line treatment. However, due to there being few treatment options for steroid-resistant acute GVHD, decisions to initiate second-line treatment are on occasion made 2-3 weeks after first-line therapy in Japan. Previous studies do not support the choice of any specific agent for second-line treatment of acute GVHD. Anti-thymocyte globulin and mesenchymal stem cells are covered by health insurance in Japan. Establishment of new evidence for GVHD treatment is required.

Third-party Wharton’s jelly mesenchymal stem cells for treatment of steroid-resistant acute and chronic graft-versus-host disease: a report of 10 cases

Severe graft-versus-host disease (GvHD) is a life-threatening complication after allogeneic hematopoietic stem cell transplantation (HSCT). Bone marrow mesenchymal stem cells (BM-MSCs) display immunosuppressive activity and have been previously shown to improve the outcome of GvHD therapy. We describe the use of umbilical cord mesenchymal stem cells (WJ-MSCs) expanded in serum-free medium for the treatment of acute GvHD (aGvHD) and chronic GvHD (cGvHD) in 10 patients. After 1 to 3 WJ-MSC infusions at a median dose of 1.5 × 106 cells/kg recipient body weight, a complete or partial response was observed in 4/7 patients with aGvHD and in 2/3 patients with cGvHD. Five out of 6 patients (83.3%) from the responders group and only 1 out of 4 nonresponders (25%) survived the follow-up. The deaths occurred in patients with acute GvHD. In the responders group, 2 patients showed complete remission of GvHD while symptoms of 4 patients were alleviated and the intensity of immunosuppressive therapy could be reduced. No serious adverse effects were observed. In conclusion, WJ-MSCs appear to be safe and can be successfully applied in the treatment of acute and chronic GvHD, but the therapeutic conditions should be optimized in prospective studies to maximize their efficacy.

Phase 1 Study of Carfilzomib for the Prevention of Relapse and Graft-Versus-Host Disease in Allogeneic Hematopoietic Cell Transplantation for High-Risk Hematologic Malignancies

Allogeneic hematopoietic cell transplant (HCT) remains the primary curative option for patients (pts) with poor-risk hematologic malignancies, but graft-versus-host disease (GVHD) and relapse remain major obstacles. Of note, GVHD therapy with systemic steroid and more potent immunosuppression abrogates graft-versus-tumor effect and further increases relapse. The NF-κB signaling pathway has a pivotal role in maintaining malignant cell survival and in mediating inflammatory and immune response by promoting activated T and dendritic cell function and survival. Inhibition of proteasome function results in down-regulation of the NF-κB signaling pathway, thus selective apoptosis of malignant cells, in which this pathway is up-regulated, and of allo-reactive T and dendritic cells. The reversible proteasome inhibitor bortezomib may abrogate GVHD and relapse based on pre-clinical studies and a phase 1/2 clinical trial when added to high-risk mismatched unrelated donor HCTs for pts with hematologic malignancies. (Koreth J, et al. J Clin Oncol 2012;30(26):3202-8.) Carfilzomib is a second-generation irreversible immunoproteasome inhibitor, with potentially increased efficacy and specificity to the immune and hematologic malignancy cells. It has a less off-target toxicity profile, especially myelosuppression, neuropathy and diarrhea. We are exploring the addition of carfilzomib to fludarabine-based conditioning regimens and GVHD prophylaxis with tacrolimus and methotrexate.Primary Objective: To identify the maximal tolerated dose (MTD) of carfilzomib when administered on day +1, +2, +6, +7.Methods: The phase 1 design is standard 3+3. Eligible conditioning regimens include fludarabine/busulfan and fludarabine/melphalan. Tacrolimus is started on day -3 and tapered off by day +180 if ≥grade II acute GVHD do not occur. Methotrexate 5 mg/m2 is given IV on day +1, +3, +6, +11. Carfilzomib is administered IV on days +1, +2 at 20 mg/m2/day fixed dose and on day +6, +7 at 4 dose levels: 20, 27, 36, 45 mg/m2/day. Premedication with 4 mg dexamethasone IV is administered prior to each dose of carfilzomib 20 and 27 mg/m2 and with 8 mg prior to each dose of 36 and 45 mg/m2, respectively. Carfilzomib is given after IV methotrexate on day +1 and +6. Subcutaneous filgrastim 5 μg/kg/day is started on day +1 until engraftment. Dose-limiting toxicities (DLTs) are defined as any ≥grade 3 non-hematologic National Cancer Institute Common Terminology Criteria for Adverse Events version 4 toxicities which occur within 28 days of carfilzomib treatment (day +35) and are directly attributed to carfilzomib.Results: Since October 2014, 10 pts (Male: Female, 5:5) have been enrolled. Nine pts received all planned 4 doses and 1 female received 3 doses only before being removed due to unrelated infectious adverse events. Among 9 evaluable pts, the median age was 55 (range, 29-61) years; all donors were 8/8 matched (7 sibling, 2 unrelated). Stem cell sources were peripheral blood in 8 and bone marrow in 1 unrelated donor. Primary diseases included FLT3-ITD+ acute myeloid leukemia in 2, acute bi-phenotypic leukemia in 1, BCR/ABL+ acute lymphoblastic leukemia in 1, myelodysplastic syndrome in 2, lymphoma in 2, and multiple myeloma in 1. All pts received the myeloablative reduced-toxicity fludarabine and busulfan x 4 (FluBu4), with busulfan kinetics targeting the concentration at steady state at 600-900 ng/mL. One pt with diffuse large B cell lymphoma received rituximab-FluBu4. All 9 pts engrafted neutrophil and platelet at a median time of 10 (range, 10-15) and 12 (9-14) days, respectively. A pt of dose level 2 (20/27 mg/m2) who received a bone marrow stem cell dose of 1.3 x 106 CD34+ cells/kg unexpectedly engrafted as early as day +15. Expected common toxicities related to the FluBu4 treatment was oral mucositis. Median CD33+ and CD3+ donor chimerisms were 100% and 88% at day 30, respectively, and were 100% and 91% at day 100, respectively. As of 8/4/15, no DLTs occurred in the 8 pts who had passed day +35, with the median transplant day of day +172 (range, 65-292). The 9th pt of dose level 3 (20/36 mg/m2) is day +14 and has engrafted.Conclusion: Adding the irreversible immunoproteasome inhibitor carfilzomib to fludarabine-based conditioning HCT appears safe and feasible. Dose escalation to level 4 (20/45 mg/m2) is ongoing and the results will be updated at the meeting. DisclosuresPawarode:Onyx Pharmaceuticals: Research Funding. Off Label Use: Carfilzomib is an irreversible proteasome inhibitor and is FDA approved for treament of relapsed refractory multiple myeloma. It is here being investigated for its immunomodulatory and anti-tumor properties in the prevention of graft-versus-host disease (GVHD) and disease relapse when incorporated into fludarabine based conditioning and GVHD prophylaxis regimens for allogeneic hematopoietic cell transplantation in patients with high-risk hematologic malignancy.. Levine:Novartis: Consultancy.

Alemtuzumab-Cyclosporine Versus Tacrolimus-Methotrexate-Sirolimus for Graft-Versus-Host Disease Prophylaxis in Reduced Intensity Allogeneic Hematopoietic Stem Cell Transplantation from Unrelated Donors: Final Results of a Randomized Trial

Introduction: Allogeneic hematopoietic stem cell transplantation (alloHSCT) can provide a curative therapy for hematological malignancies but may result in complications such as relapse, infection, and acute and chronic graft versus host disease (GVHD). Two divergent approaches to GVHD prophylaxis (post-HSCT depletion of donor lymphocytes vs. suppression of immune activation) in a reduced-intensity, matched-unrelated donor setting were compared in a randomized, open label, phase 2 prospective trial (NCT00520130), powered to assess the incidence of severe cGVHD using NIH criteria.Methods: Hematological malignancy patients received disease-specific induction chemotherapy DA-EPOCH-FR or FLAG (Salit et al, JCO 2012; 30:830) for disease control and host lymphodepletion to CD4+ cell target <100/µl. All patients received identical conditioning with concurrent fludarabine (30 mg/m2/d x4) and cyclophosphamide (1200 mg/m2/d x4), followed by mobilized T-replete peripheral blood allograft from a matched unrelated donor. Patients were randomized to receive alemtuzumab 20 mg/d x5 and cyclosporine (AC) or tacrolimus, sirolimus, and methotrexate (TMS).Results: 81 pts (NHL=25, HL=8, CLL=18, AML/MDS=10, CML=3, CTCL/PTCL=5, ALL=4, MM=2, other=6), median age 50 yrs (range, 21-71) were included in the study (AC=42, TMS=39). The two arms were similar in age, gender, disease, relapse risk (Kahl), HCT-comorbidity index, and donor HLA match (8/8 or 7/8). Median time to neutrophil engraftment was 9 vs. 11 days in AC vs. TMS, respectively (p=0.017). There were no differences in platelet recovery (p=0.96). One case of graft failure occurred in a myeloma patient on the AC arm.D100 mortality probabilities were 12% (95% CI, 5-25) and 10% (95% CI, 4-24) in AC and TMS, respectively (p=0.20). Median survival in AC was 18.8 mo and 41.7 mo in TMS, with a median follow-up of 53 mo in AC and 50.6 mo in TMS. 3yr OS was comparable: AC 42% (95% CI, 28-57) vs. TMS 58% (95% CI, 42-73) (p=0.20). The 3yr malignancy progression rate was higher in the AC arm (AC 51% (95% CI, 34-65) vs. TMS 21% (95% CI, 10-35), p= 0.0062). 3yr relapse related mortality rates were 29% (95% CI, 16-44) vs. 14% (95% CI, 5-29) (p=0.067) and non-relapse mortality 29% (95% CI, 16-43) vs. 28% (95% CI, 14-43) (p=0.75) in AC vs. TMS, respectively. The most common grade ≥3 adverse events (CTCAE 4.03) within 100 d post-transplant were infections (22%) with more viral infections in the AC arm (p=0.0007). Reactivation of CMV occurred earlier in the AC arm, incidence 58% (95% CI, 42-71) vs. 24% (95% CI, 12-38) by D100 (p=0.035).Rates of aGVHD were similar; Gr II-IV at 6 mo in AC 38% (95% CI, 23-53) vs. TMS 41% (95% CI, 26-57) (p=0.59); Gr III-IV at 6 mo AC 21% (95% CI, 11-35) vs. TMS 13% (95% CI, 5-26) (p=0.61). In contrast, significantly lower rates of any grade cGVHD occurred in the AC arm compared to TMS at 36 mo (27% (95% CI, 14-41) vs. 59% (95% CI, 40-74)) (p=0.0076). The incidence of severe cGVHD was strikingly different: AC 5% (95% CI, 1-15) vs. TMS 31% (95% CI, 16-47) (p=0.0007). In the Cox model, the only prognostic factor for severe or any cGVHD was the TMS treatment arm, HR 6.8 (95% CI, 1.5-30.3, p=0.012) and HR 2.3 (95% CI, 1.1-4.8, p=0.026), respectively.Lymphocyte recovery (ALC 500/µL) was markedly delayed in AC, median 76 vs. 16 d (p<0.0001). NK-cell recovery was disparate during the first month (p <0.0001, D28: 31 vs. 270/µl), but similar thereafter. B-cell reconstitution was negligible in both through 6 mo. AC resulted in profound and prolonged deficit in T cells. CD4+ cells were significantly reduced in AC vs. TMS through 1 yr (p <0.0001, D28: 21 vs. 285/µl, 1yr: 131 vs. 447/µl). CD8+ disparity persisted for 6 mo (p<0.0001, D28: 6 vs. 205/µl, 6 mo: 58 vs. 429/µl). Naïve T-cells were significantly reduced in AC through 6 mo (p<0.0001, median naïve cell frequency (AC vs TMS) Treg 2.8 vs 8.4%; nonTreg CD4+ 1.0 vs 23.7%; CD8+ 2.9 vs 20.0%). Assessment of CD4+ and CD8+ TCR Vβ repertoire diversity by spectratyping demonstrated significantly lower diversity in AC at 6 mo (p=0.003).Conclusions: This prospective, randomized trial demonstrates that the use of AC when compared with TMS led to a significant reduction in incidence of severe and overall cGVHD. These two GVHD prophylaxis regimens had similar incidences of aGVHD but very different effects on post-alloHSCT immune reconstitution, infection and relapse. Future strategies for cGVHD prevention will need to further address these issues. DisclosuresOff Label Use: There is currently no FDA approved product for GVHD prevention or therapy. The GVHD prophylaxis regimens described in this study (Alemtuzumab-Cyclosporine and Tacrolimus-Methotrexate-Sirolimus) are used off-label as GVHD prophylaxis regimens in reduced-intensity allogeneic HSCT.

Targeting the IL-2/CD25 and TL1A/TNFRSF25 Pathways: A New Approach to Markedly Expand Donor Tregs in Multiple Compartments Leads to in Situ Immune Regulation

Regulatory T cells (Treg) are critical for the maintenance of self-tolerance and Treg expansion is being investigated as a promising therapy for graft-versus-host disease (GVHD) after allogeneic stem cell transplantation. Because the numbers of donor graft Tregs necessary for maximal efficacy are significant, ex vivo expansion presents both practical and scientific challenges. We and others have demonstrated that in situ expansion of CD4+ FoxP3+ Tregs using IL-2 may be used to inhibit alloreactive T cells that mediate GVHD. Recently, we developed a novel combination approach to expand donor Tregs, wherein we administered a fusion protein (TL1A-Ig) and IL-2, which target, respectively, TNF receptor super family 25 (TNFRSF25) and CD25, the high affinity IL-2 receptor. Following a 6-day sequence of Tl1A-Ig and IL-2, we observed markedly greater peripheral Treg expansion (5-8 fold) vs. either reagent alone (2-3 fold). The resulting Treg expansion in healthy animals is transient, peaking by 7-8 days, and results in no long-term complications, as assessed by changes in blood counts, immune phenotype / function and tissue pathology 6 months following cessation of treatment. Analyses of animals 1 week following sequential therapy revealed Treg expansion in blood, spleen, lymph nodes, and the colon but not bone marrow. Expanded Tregs were highly activated (Ki67+) with an elevated KLRG1+ fraction. High functional activity was also reflected in their hypomethylated FoxP3 promoter region, elevated pSTAT5 expression and the ability of sorted Tregs to mediate functional suppression of lymphocyte proliferation. Notably, assessment of the splenic vs. LN Treg compartment indicated that there were consistently higher Treg frequencies an d greater levels of Treg effector proteins (Gzmb/TNFa/IFNg/IL-10) in the splenic Treg compartment. To assess the functional significance of this difference, we stimulated splenocytes and lymph node cells from TL1A-Ig/IL-2 treated animals with anti-CD3 mAb and LPS, and observed significantly greater suppression in the spleen vs LN cultures. Importantly, even when cultures of LN cells contained the same or greater numbers of Tregs compared with the spleen, greater suppression was detected in the splenic cultures. Based on the heightened suppressive environment in spleens post-Treg expansion, we performed HSCT across a complete MHC mismatch using the B6àBALB/c donor/recipient combination. Groups of 8.5 Gy TBI-conditioned mice received T cell depleted B6 bone marrow and either spleen or LN cells from TL1A-Ig/IL-2 treated or untreated B6 mice. While GVHD was reduced in recipients of either spleen or lymph node T cells, relative to recipients of control (non-expanded) donors, suppression of GVHD was significantly greater in recipients of spleen cells (by weight loss, clinical score and survival). In summary, we have identified a novel strategy to rapidly and transiently expand donor Treg cell numbers in situ. The splenic compartment contained increased numbers and more functionally active Tregs compared to lymph nodes. Overall, TL1A-Ig/IL-2 expanded Tregs demonstrated excellent suppressive function both ex vivo and in vivo, as assessed by GVHD incidence and severity following allogeneic transplantation. This approach may be a promising strategy for GVHD prevention or therapy in the clinical setting. [Display omitted] DisclosuresPodack:Heat Biologics: Equity Ownership, Patents & Royalties: Dr. Podack is an inventor of patents used in the study and stands to gain royalties from future commercialization of "immunomodulating tumor necrosis factor receptor 25 (TNFR25) agonists, antagonists and immunotoxins, Research Funding. Levy:Allergan: Consultancy.