Hepatic Graft-versus-host Disease Research Articles

HLA-mismatched donor and high ferritin level showed poor clinical outcomes after allogeneic hematopoietic cell transplantation in patients with advanced myelofibrosis.

Background:Preconditioning intensity, donor choice and graft-versus-host disease (GVHD) prophylaxis of allogeneic hematopoietic cell transplantation (allo-HCT) for advanced myelofibrosis (MF) have not been fully elucidated.Methods:Thirty-five patients with advanced MF were treated with reduced-intensity conditioning (RIC) allo-HCT. We searched for matched sibling donors first, followed by matched or mismatched unrelated donors and familial mismatched donors. Preconditioning regimen consisted of fludarabine (total 150 mg/m2) and busulfan (total 6.4 mg/kg) with total body irradiation ⩽400cGy.Results:All showed engraftments, but four showed either leukemic relapse or delayed graft failure. Two-year overall survival (OS) and non-relapse mortality (NRM) was 60.0% and 29.9%, respectively. Acute GVHD was observed in 19 patients, and grade III–IV acute GVHD (eight grade III and four grade IV) was higher in human leukocyte antigen (HLA)-mismatched donor HCT compared with HLA-matched HCT (70% versus 20%). Chronic GVHD was observed in 16 patients, and a cumulative incidence of severe chronic GVHD was 33% in HLA-mismatched donor HCT and 7.7% in HLA-matched HCT. Significant hepatic GVHD was observed in nine patients (five acute, four chronic) and six of them died. Multivariate analysis revealed inferior OS in HLA-mismatched donor HCT (hazard ratio (HR) = 6.40, 95% confidence interval (CI) 1.6–25.7, p = 0.009) and in patients with high ferritin level at the time of pre-conditioning period (HR = 7.22, 95% CI 1.9–27.5, p = 0.004), which were related to higher incidence of hepatic GVHD with high NRM rate.Conclusion:RIC allo-HCT can be a valid choice providing graft-versus-fibrosis effect for advanced MF patients. However, HLA-mismatched donor and high pre-HCT ferritin level related to fatal hepatic GVHD should be regarded as poor-risk parameters.

Evaluation of the demographic and clinical findings of pediatric patients that developed acute graft-versus-host disease after allogeneic hematopoietic stem cell

Aim: Acute graft-versus-host disease (GVHD) is an complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT), manifesting with an erythematous maculopapular rash followed by liver disease and dysfunctions of the gastrointestinal tract. This study aimed to retrospectively investigate the demographic and clinical characteristics of pediatric patients diagnosed with acute GVHD after undergoing allo-HSCT due to various hematological diseases.Material and Methods: The study included 33 pediatric patients that underwent their first allogeneic bone marrow transplantation in the Pediatric Bone Marrow Transplant Unit between 2015 and 2018 and were consecutively diagnosed with acute GVHD in consultation with the department of dermatology. The demographic characteristics, clinical findings, donor characteristics, treatments, and survival status of each patient were recorded.Results: Between 2015 and 2018, bone marrow transplantation was performed in 150 pediatric patients, of whom 33 (22%) developed acute GVHD. Of the 33 pediatric patients, 19 (57.6%) were boys and 14 (42.4%) were girls. At the time of transplantation, the mean age of the patients was 8.5 years, and the median age was 7 years. Twenty patients (60.6%) had only skin GVHD while 13 (39.4%) had skin and gastrointestinal and/or hepatic GVHD. It was found that the rashes had appeared on average 27.4 days after allo-HSCT. Palmoplantar involvement was detected in 13 patients (39.4%), painful erosion in the oral mucosa in 11 (33%), and conjunctivitis in seven (21.2%). The factors of being a male patient, being a female donor, transplantation from unrelated donors, liver involvement, and palmoplantar involvement were found to create risk of mortality, but not significantly (respectively p=0,753;p=0,145,0,66). Five patients (15%) progressed from acute to chronic GVHD. In patients that progressed from acute to chronic had, the mean donor age was higher, the mean time from transplantation to rash was longer, and oral involvement was higher, but not significantly (respectively; p=0,596;p=0,980;p=0,193.Conclusion: In acute GVHD, the skin is the first and most involved organ; therefore, dermatologists play an important role in its diagnosis. This study is important for determining the factors affecting the decrease in progression to chronic GVHD and prolonging survival.

Poor Outcomes of HLA-Mismatched Allogeneic Hematopoietic Cell Transplantation and High Ferritin Levels after a Reduced-Intensity Conditioning Regimen in Patients with Advanced Myelofibrosis

Allogeneic hematopoietic cell transplantation (allo-HCT) preconditioning intensity, donor choice, and graft-versus-host disease (GVHD) prophylaxis for advanced myelofibrosis (MF) have not been fully elucidated. Thirty-five patients with advanced MF were treated with reduced-intensity conditioning (RIC) allo-HCT. We searched for matched sibling (n=16) followed by matched (n=10) or mismatched (n=5) unrelated and familial mismatched donors (n=4). Preconditioning regimen consisted of fludarabine (total 150 mg/m2) and busulfan (total 6.4 mg/kg) with total body irradiation≤ 400cGy. All showed engraftments, but four (11.4%) showed either leukemic relapse (n=3) or delayed graft failure (n=1). Two-year overall survival (OS) and non-relapse mortality (NRM) was 60.0% and 29.9%, respectively. Acute GVHD was observed in 19 patients, and grade III-IV acute GVHD was higher with HLA-mismatch (70% vs. 20%, p=0.008). Significant hepatic GVHD was observed in nine patients (5 acute, 4 chronic), and six of them died. Multivariate analysis revealed inferior OS with HLA-mismatch (HR=6.40, 95%CI 1.6-25.7, p=0.009) and in patients with high ferritin level at post-HCT D+21 (HR=7.22, 95%CI 1.9-27.5, p=0.004), which were related to hepatic GVHD and high NRM. RIC allo-HCT can be a valid choice for advanced MF. However, HLA-mismatch and high post-HCT ferritin levels related to significant hepatic GVHD should be regarded as poor-risk parameters. Disclosures Kim: Handok: Honoraria; Amgen: Honoraria; Celgene: Consultancy, Honoraria; Astellas: Consultancy, Honoraria; Hanmi: Consultancy, Honoraria; AGP: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; SL VaxiGen: Consultancy, Honoraria; Novartis: Consultancy; Janssen: Honoraria; Daiichi Sankyo: Honoraria, Membership on an entity's Board of Directors or advisory committees; Otsuka: Honoraria; BL & H: Research Funding; Chugai: Honoraria; Yuhan: Honoraria; Sanofi-Genzyme: Honoraria, Research Funding; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Lee:Alexion: Consultancy, Honoraria, Research Funding; Achillion: Research Funding.

A critical role of the Gas6-Mer axis in endothelial dysfunction contributing to TA-TMA associated with GVHD

AbstractEndothelial dysfunction in the early phases of hematopoietic stem cell transplantation (HSCT) contributes to a common pathology between transplant-associated thrombotic microangiopathy (TA-TMA) and graft-versus-host disease (GVHD), which are serious complications of HSCT. Growth arrest-specific (Gas) 6 structurally belongs to the family of plasma vitamin K-dependent proteins working as a cofactor for activated protein C, and has growth factor-like properties through its interaction with receptor tyrosine kinases of the TAM family: Tyro3, Axl, and Mer. Serum Gas6 levels were significantly increased in HSCT patients with grade II to IV acute GVHD (aGVHD), and Gas6 and Mer expression levels were upregulated in aGVHD lesions of the large intestine and skin. The increased serum Gas6 levels were also correlated with elevated lactate dehydrogenase, d-dimer, and plasmin inhibitor complex values in HSCT patients with aGVHD. In human umbilical vein endothelial cells (ECs), exogenous Gas6 or the exposure of sera isolated from patients with grade III aGVHD to ECs induced the downregulation of thrombomodulin and the upregulation of PAI-1, as well as the upregulation of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1, which were inhibited by UNC2250, a selective Mer tyrosine kinase inhibitor. In mouse HSCT models, we observed hepatic GVHD with hepatocellular apoptosis, necrosis, and fibrosis, as well as TA-TMA, which is characterized pathologically by thrombosis formation in the microvasculature of the liver and kidney. Of note, intravenous administration of UNC2250 markedly suppressed GVHD and TA-TMA in these mouse HSCT models. Our findings suggest that the Gas6-Mer axis is a promising target for TA-TMA after GVHD.

PB2297 A REAL LIFE STUDY OF QUALITY OF LIFE IN PATIENTS AFTER ALLOGENIC HAEMATOPOIETIC STEM CELL TRANSPLANTATION

Background: The study of the quality of life (QoL) in patients after allo-Haematopoietic Stem Cell Transplantation (allo-HSCT) is necessary in order to evaluate results, give more accurate information to the patients and help us with the implementation of new strategies that improve the QoL of these patients. Aims: We aim to evaluate the impact of allo-HSCT and graft versus host disease (GvHD) on QoL of patients. Methods: Our series consisted of 29 patients who received an allo-HSCT between 1996 and 2017 at our hospital. To evaluate the QoL we used the validated questionnaires of QoL SF-36, FACT-BMT (version 4) and a self-made questionnaire. We used IBM SPSS v.23 to determine univariate analysis of variance, binary logistic regression and chi squared. p value <0.05 was considered as statistically significant. Results: We contacted with 64 patients but only 29 accepted to participate on the study. On table 1 are the demographic and clinical features related to the allo-HSCT and GvHD. Regarding the SF-36 questionnaire we found a correlation between obtaining a punctuation over 70% on physical state and having a job when the questionnaire was completed (p = 0.027). When we analyzed the QoL with FACT-BMT we observed that patients transplanted less than 2 years ago presented a worse QoL than those transplanted 2 or more years ago (p = 0.001), but did not observe this statistically significant difference with SF-36. We found that patients with a low result for mental state under SF-36 show a worse QoL measured by FACT-BMT (p = 0.004). On the sub-scales analysis we found a statistically significant relation between patients with hepatic chronic GvHD and a decrease on the physical well-being (p = 0.035) and functional well-being (p = 0.006) measured with FACT-BMT. We also observed a lower punctuation on functional well-being for patients with ocular (p = 0.015), cutaneous (p = 0.016) and hepatic (p = 0.006) chronic GvHD. We observed that 44.8% of patients presented sexual symptoms of which 10.3% described pain, what could suggest the presence of genital GvHD. We found no statistically significant correlation between the result of SF-36 and FACT-BMT.Summary/Conclusion: There is a negative impact on QoL of patients with hepatic and digestive chronic GvHD. McQuellon et al in 1198 reported that the recovery path of transplanted patients present a parabolic tendency improving after day 100. We observed a worse QoL by FACT-BMT on patients being on the 2 years post-HSCT. This suggests that the first years post-transplant is when the evaluation of the quality of life could bring more benefit to patients. When comparing the two tests used FACT-BMT (version 4) and SF-36, no statistically significant relationship was found between the results of both, which suggests that the application of a single test may be insufficient when assessing the patient's integral form. Allo-HSCT impacts on a negatively on QoL of patients, especially on those developing GvHD and we need to develop new tools allowing us to evaluate globally the patients.

Acute transaminitis as an atypical presentation of Graft-versus-Host Disease following Hematopoietic Stem Cell Transplantation

Graft versus Host Disease (GVHD) can present with mucocutaneous, gastrointestinal and hepatic manifestations, specifically a cholestatic transaminitis. Rarely, some cases can present with only a hepatocellular transaminitis. Our patient presented with an acute hepatitis on day +90 post-hematopoietic stem cell transplant, without other overt manifestations of GVHD. The initial work up was negative for a viral etiology or causative drug, and the patient’s transaminases continued to rise. On day +96, an erythematous rash appeared with biopsy indicating lymphocytic and eosinophilic infiltrates concerning for cutaneous GVHD. Subsequently, a liver biopsy was obtained, and showed marked ductopenia with cholestasis, consistent with hepatic GVHD.

A Critical Role of Growth Arrest-Specific Gene 6-Mer Axis in the Pathogenesis of Endothelial Damage Contributing to Thrombotic Microangiopathy Associated with Graft-Versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation

Graft-versus-host disease (GVHD) and thrombotic microangiopathy (TMA) are severe complications of allogeneic hematopoietic stem cell transplantation (allo-SCT). Host endothelial cells are targets of alloreactive donor cytotoxic T lymphocytes or various proinflammatory cytokines following allo-SCT, and endothelial damage plays an important role in the pathogenic mechanism(s) of TMA associated with GVHD. However, the detailed mechanism(s) of TMA as well as GVHD have not yet been fully elucidated. Growth arrest-specific (Gas) 6 structurally belongs to the family of plasma vitamin K-dependent proteins working as a cofactor for activated protein C, and has growth factor-like properties through its interaction with receptor tyrosine kinases of the TAM family; Tyro3, Axl, and Mer. Gas6 and the TAM receptor tyrosine kinases have been reported to be associated with systemic inflammatory and autoimmune disorders, as well as hemostatic abnormalities. We hypothesized that Gas6-TAM pathway signaling contributed to endothelial dysfunction in the pathogenesis of TMA associated with GVHD. ELISA showed that the serum levels of Gas6 were markedly increased in the all-SCT patients with grades 2 or 3 GVHD at 21-35 days after stem-cell engraftment. The increased serum levels of Gas6 were also correlated with the elevated D-dimer and plasmin-α2 plasmin inhibitor complex values in the allo-SCT patients. Immunostaining showed that the expression of Gas6 and Mer was significantly upregulated in the intestinal acute GVHD lesion. The platelet aggregation test showed that UNC2250 (5 μM), a selective Mer tyrosine kinase inhibitor markedly suppressed increased platelet aggregation caused by exogenous Gas6 and collagen. Using Western blot analysis, exposure of human umbilical vein endothelial cells (ECs) to, Gas6 or 25-50% (vol/vol) serum isolated from patients with GVHD caused the downregulation of thrombomodulin (TM) and plasminogen activator inhibitor type-1 (PAI-1) as well as the upregulation of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1), as assessed by Western blot analyses, which were inhibited by UNC2250 or Mer siRNA. Furthermore, exogenous Gas6 or the addition of serum from patients with GVHD to ECs induced apoptosis of ECs with activation of caspase-3 and poly (ADP-ribose) polymerase, which were inhibited by UNC2250 or Mer siRNA. These results indicate that the Gas6-Mer axis may be crucial for platelet activation, endothelial damage and subsequent hypercoagulation in the pathogenesis of TMA associated with GVHD after allo-SCT. Furthermore, in the murine models of allo-SCT, we observed hepatic GVHD with hepatocellular apoptosis, necrosis and fibrosis and TMA characterized by thrombosis formation in the microvasculature of liver and kidney. The intravenous administration of 3 mg/kg UNC2250 markedly inhibited hepatic GVHD and TMA formations of liver and kidney in murine models of allo-SCT at 21 days after allo-SCT. The present study provides new evidence that the Gas6-Mer axis may be involved in the mechanism(s) underlying the progression of the pathogenesis of TMA associated with GVHD after all-SCT. We suggest that Gas6-Mer axis may be an attractive therapeutic target for treating TMA associated with GVHD caused by endothelial damage. DisclosuresNo relevant conflicts of interest to declare.

Sequential CD19- and CD22-CART Cell Therapies for Relapsed B-Cell Acute Lymphoblastic Leukemia after Allogeneic Hematopoietic Stem Cell Transplantation

With traditional therapies, the prognosis of relapsed acute lymphoblastic leukemia (ALL) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is extremely poor. Chimeric antigen receptor (CAR) T cell therapy targeting at CD19 has demonstrated a significant efficacy on refractory/relapsed (r/r) B-ALL, but single-target CART could not maintain a long-term remission. Recently, CD22-CART has also shown an exciting result in r/r B-ALL. Here we sequentially applied CD19- and CD22-specific CART cells to treat relapsed B-ALL post-HSCT and observed the therapeutic effect.From June 30,2017 through May 31,2018, twenty-four B-ALL patients (pts) relapsing after allo-HSCT with both antigens CD19 and CD22 expression on blasts were enrolled, the median age was 24 (2.3-55) years. Seventeen pts had hematologic relapse, 6 with both bone marrow and extramedullary (EM) involvements and 1 with EM disease (EMD) only. Fourteen pts had failed to previous therapies including chemotherapy, donor lymphocyte infusion, interferon and even murinized CD19-CART in other hospitals.Recipient-derived donor T cells were collected for producing CAR-T cells, which were transfected by a lentiviral vector encoding the CAR composed of CD3ζ and 4-1BB. Eighteen pts were initially infused with murinized CD19-CART, then humanized CD22-CART; while 6 pts (5 failed to prior murinized CD19-CART and 1 had bright CD22-expression) were initially infused with humanized CD22-CART, then humanized CD19-CART. The time interval between two infusions was 1.5-6 months based on patients' clinical conditions. The average dose of infused CAR T cells was 1.4×105/kg (0.4-9.2×105/kg) for CD19 and 1.9×105/kg (0.55-6.6×105/kg) for CD22. All patients received fludarabine with or without cyclophosphamide prior to each infusion, some pts accepted additional chemo drugs to reduce the disease burden. Treatment effects were evaluated on day 30 and then monthly after each CART, minimal residual disease (MRD) was detected by flow cytometry (FCM) and quantitative PCR for fusion genes, EMD was examined by PET-CT, CT or MRI.Sixteen patients finished sequential CD19- and CD22-CART therapies. Three cases could not undergo the second round of CART infusion (1 died, 1 gave up and 1 developed extensive chronic graft-versus-host disease (GVHD)). The rest of 5 pts are waiting for the second CART. After first T-cell infusion, 20/24 (83.3%) pts achieved complete remission (CR) or CR with incomplete count recovery (CRi), MRD-negative was 100% in CR or CRi pts, 3 (12.5%) cases with multiple EMD obtained partial remission (PR), and 1 (4.2%) died of severe cytokine release syndrome (CRS) and severe acute hepatic GVHD.Sixteen patients (15 CR and 1 PR) underwent the second CART therapy. Before second infusion, 3/15 pts in CR became MRD+ and others remained MRD-. On day 30 post-infusion, 1 of 3 MRD+ pts turned to MRD-, 1 maintained MRD+ ( BCR/ABL+) and 1 had no response then hematologic relapse later. The PR patient still had not obtained CR and then disease progressed. As of 31 May 2018, at a median follow-up of 6.5 (4-10) months, among 16 pts who received sequential CD-19 and CD-22 CART therapies, 1 had disease progression, 2 presented with hematological relapse and 2 with BCR/ABL+ only, the overall survival (OS) rate was 100% (16/16), disease-free survival (DFS) was 81.3% (13/16) and MRD-free survival was 68.8% (11/16).CRS occurred in 91.7% (22/24) pts in the first round of T-cell infusion, most of them were mild-moderate (grade I-II), merely 2 pts experienced severe CRS (grade III-IV). The second CART only caused grade I or no CRS since the leukemia burden was very low. GVHD induced by CART therapy was a major adverse event in these post-HSCT patients. After the first CART, 7/24 (29.2%) pts experienced GVHD, of them, 4 presented with mild skin GVHD, 2 with severe hepatic GVHD (1 recovered and 1 died), and 1 developed extensive chronic GVHD. No severe GVHD occurred in the second infusion.Our preliminary clinical study showed that for B-ALL patients who relapsed after allo-HSCT, single CD19- or CD22- CART infusion resulted in a high CR rate of 83.3%, sequentially combined CD19- and CD22-CART therapies significantly improved treatment outcome with the rate of OS, DFS and MRD-free survival being 100%, 81.3% and 68.8%, respectively, at a median follow-up of 6.5 months. The effect of CART on multiple EMD was not good and CART induced GVHD needs to be cautious. DisclosuresNo relevant conflicts of interest to declare.

Ruxolitinib: a steroid sparing agent in chronic graft-versus-host disease.

Inhibition of the Janus-associated kinases (JAK) with ruxolitinib (RUX) reduces graft-versus-host disease (GVHD) in preclinical and clinical models. In total 19 allograft recipients with moderate/severe steroid-dependent chronic GVHD received RUX as ≥2nd line salvage. RUX was well tolerated, and led to complete/partial resolution of oral (92/7%), cutaneous (82/0%), hepatic (71/28%), gastro-intestinal (75/17%), musculoskeletal (33/67%), pulmonary (0/80%), scleroderma (0/75%), vaginal (0/75%), and ocular (0/100%) chronic GVHD. Overall 18 achieved partial response and 1 complete response according to NIH Consensus Criteria. Responses occurred early and were sustained which enabled discontinuation (68%) or reduction of steroids to physiologic doses (21%). We conclude that RUX is an effective steroid-sparing agent in chronic GVHD.

Concurrent Hepatic Tuberculosis and Hepatic Graft-versus-host Disease in an Allogeneic Hematopoietic Stem Cell Transplant Recipient: A Case Report

BackgroundInfection and graft-versus-host disease (GVHD) are among the most common complications after hematopoietic stem cell transplantation (HSCT). With well-known risk factors including allogeneic HSCT and GVHD, tuberculosis (TB) has a higher incidence and shorter survival rate in HSCT recipients than in the general population. Case ReportA 55-year-old Indonesian female with a history of latent TB was found to have acute myeloid leukemia 3 months after allogeneic HSCT. She presented with fever, abdominal pain, and predominant cholestatic-type liver function tests derangement. Computed tomography scans showed a relatively unremarkable liver. Liver biopsy specimens revealed multiple necrotizing granulomas with numerous acid-fast bacilli shown using Ziehl-Neelsen histochemical stain. No fungal organisms are detected by Grocott's methenamine silver and periodic acid–Schiff stains. There was also mild portal hepatitis with prominent bile duct injury and scattered apoptotic bodies, compatible with GVHD. In addition, the patient was also discovered to have cutaneous and intestinal TB as well as cutaneous and colonic GVHD during investigation. She was started on anti-TB treatment and adjusted immunosuppression scheme accordingly. Unfortunately, our patient died of spontaneous intracranial haemorrhage approximately 2 months after the diagnosis of post-transplantation TB and GVHD. ConclusionWe report a case of concurrent hepatic TB and GVHD in an allogeneic HSCT recipient. Recognition of the dual pathology in the biopsy results aids proper treatment.

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.

Presence of GvHD and Fever of Unknown Origin Could be a Tubercular Infection Post Allogenic Hematopoietic Stem Cell Transplant

IntroductionPatients post allogeneic stem cell transplant (allo SCT) are expected to be at high risk of tuberculosis (TB) due to underlying immunosuppression. The incidence is predicted to be higher in countries endemic to TB, like ours. We conducted a retrospective study of post alloSCT patients for incidence of TB, its clinical presentation, factors associated with TB and its outcome.MethodsRecords of all patients who underwent allo SCT from 1st January 2012 till 31st December 2015 were reviewed for transplant related parameters and tubercular infection. The diagnosis of tuberculosis was considered if Mycobacterium tuberculosis (MTB) cultured from clinical samples or acid fast bacilli (AFB) demonstrated on histopathology/ smears. A possible TB was considered in presence of epitheloid cell granulomas without AFB. Patients already on anti-tubercular therapy (ATT) at the time of SCT or had any history of TB were excluded from study population.ResultsA total of 176 patients underwent allo SCT in study period with one patient having past history of TB lymphadenitis (excluded from further analysis). Indications for allo SCT were malignant diseases and non-malignant diseases in 82.3% (n=144) and 17.7% (n=31) patients respectively. Conditioning regimen was myeloablative in 57.7%(n=101) and reduced intensity in 20.6% (n=36) and non myeloablative in 21.7% (n=38). Total body irradiation (TBI) based myeloablative regimen was used in 24.5% (n=43) of patients. Anti-thymocyte globulin (ATG) was used in 14.8% of conditioning regimen. 19 patients underwent unrelated allotransplants. Overall 94 (53.7%) of patients experienced any graft vs host disease (GvHD) (acute 37% (n=65), chronic 29% (n=51) of all patients). Treatment related mortality in the study population was 26.3% (n=46) and overall survival was 50.3% (n=88) at 345 days of median follow up.Tuberculosis was detected in 5 patients (3 males, 2 females), none had a history of contact with TB, who underwent allo SCT (related =4, unrelated =1). Peripheral blood was used as graft source in all with myeloablative non TBI based conditioning regimen used in 2 patients while TBI based myeloablative conditioning regimen in 1 patient and reduced intensity conditioning in rest 2 patients. ATG was used in one patient for conditioning. Median ECOG performance score of all the 5 patients was 1 (0-1). Only one patient (diagnosis- acute lymphoblastic leukemia) received steroid based treatment as a part of pre transplant treatment during induction chemotherapy. Four patients developed pulmonary tubercular infection while one had lymph nodal involvement after allogeneic SCT, accounting to an incidence rate of tubercular infection of 2.8% at a median of 258 days post allo SCT. The presenting symptoms for TB were unexplained fever (n=4), weight loss (n=1), chest pain (n=2), cough with expectoration (n=1) which lasted for a median of 20 days till TB diagnosis was confirmed using lung biopsy (n=3), BAL culture (n =1) and lung FNA (n=1).All 5 patients had GvHD in one of its form and four patients who presented with pulmonary disease were receiving median number of 2 (1-3) immunosuppressive therapies at the time of TB diagnosis. Four patients with acute GvHD had received steroids as part of treatment. Presence of any GvHD and chronic GvHD was found to be significantly associated with Tubercular infection (p=0.042) and (p=0.002) respectively as per Fischer exact test. Acute GvHD, though present in 4/5 patients, had a trend towards Tubercular infection (p=0.058) (Table 1).All patients were started on 4 drug ATT with clinical/ radiological response in all. One patient developed transaminitis post 7 days of start of ATT for which dose modification was done and the other patient developed hyperbiluribinemia, which required temporary cessation of ATT. All the patients who developed TB are alive with a median overall survival of 1071 days post allo SCT.ConclusionThe incidence of TB is very high amongst allo SCT recipients, as compared to general population. Tuberculosis should be suspected in patients with unexplained fever post allogeneic SCT. Most of cases are pulmonary TB. Active GvHD and ongoing immunosuppression/ steroids are possible risk factors. Early diagnosis and treatment can salvage most of these patients and prevent long term morbidity and mortality. Hepatic toxicity following ATT is common and needs to be differentiated from hepatic GvHD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Anti-thymocyte globulin-induced hyperbilirubinemia in patients with myelofibrosis undergoing allogeneic hematopoietic cell transplantation.

Allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative treatment option for myelofibrosis (MF) despite the emergence of novel targeted therapies. To reduce graft rejection and graft-versus-host disease (GvHD), current allo-HCT protocols often include in vivo T lymphocyte depletion using polyclonal anti-thymocyte globulin (ATG). Shortly after ATG administration, an immediate inflammatory response with fever, chills, and laboratory alterations such as cytopenias, elevation of serum C-reactive protein, bilirubin, and transaminases can develop. Here, we explore whether MF patients, who commonly exhibit extramedullary hematopoiesis in the liver, might be particularly susceptible to ATG-induced liver toxicity. To test this hypothesis, we analyzed 130 control and 94 MF patients from three transplant centers treated with or without ATG during the allo-HCT conditioning regimen. Indeed, hyperbilirubinemia was found in nearly every MF patient treated with ATG (MF-ATG 54/60 = 90%) as compared to non-ATG treated MF (MF-noATG 15/34 = 44.1%, p < 0.001) and respectively ATG-treated non-MF patients of the control group (control-ATG, 43/77 = 56%, p < 0.001). In contrast, transaminases were only inconsistently elevated. Hyperbilirubinemia was in most cases self-limiting and not predictive of increased incidence of non-relapse mortality, hepatic sinusoidal obstruction syndrome (SOS) or liver GvHD. In sum, awareness of this stereotypic bilirubin elevation in MF patients treated with ATG provides a relatively benign explanation for hyperbilirubinemia occurring in these patients during the early transplant. However, attention to drug levels of biliary excreted drugs is warranted, since altered bile flow may influence their clearance and enhance toxicity (e.g., busulfan, antifungal agents).

Seattle Regimen RIC-HSCT in Early-Phase Multiple Myeloma: A Multi-Centre Experience Demonstrating Very Low Treatment-Related Mortality and Rapid Graft-Versus-Myeloma Effect Associated with Graft-Versus-Host Disease

▪Introduction: The introduction of novel agentshas revolutionised the treatment of multiple myeloma, with improvements in survival of newly diagnosed and relapsed/refractory patients. However, despite these advances, the role for allogeneic haematopoietic stem cell transplantation (HSCT) in the treatment of these patients remains in question.Reduced-intensity conditioning (RIC) HSCT with Seattle regimen (30 mg/m2 fludarabine and 2 Gray total-body irradiation, TBI) for multiple myeloma has been reported to be an effective treatment with low upfront toxicity, and the potential for graft-versus-myeloma effect (Niederwieser D et al, Blood, 2003). Its use as part of tandem HSCT (autologous HSCT followed by RIC-HSCT) is associated with a treatment-related mortality (TRM) rate as low as 15% (Björkstrand B et al, J Clin Onc, 2011). However, data on survival following auto-HSCT/RIC-HSCT is inconsistent and no unifying consensus has been reached regarding the optimal timing of RIC-HSCT in the treatment algorithm. In this retrospective multi-centre study, we investigated the safety, tolerability and efficacy of RIC-HSCT in multiple myeloma patients in remission following previous auto-HSCT.Methods: A retrospective series was conducted for early-phase, high-risk myeloma patients who underwent RIC-HSCT following prior auto-HSCT in two tertiary transplant centres in Manchester in North West England, between November 2006 and July 2014.Results: Over the eight-year period, 42 myeloma patients (male n=29, female n=13) underwent Seattle-conditioned RIC-HSCT following prior auto-HSCT. 66.6% (n=28) were performed in tandem. Median age at RIC-HSCT was 52 years (range 41-65), and median β2-microglobulin at diagnosis was 3.1 mg/L (range 1.6-18.0). 16 patients had cytogenetics assessed at the time of diagnosis, of which loss of TP53 and translocation of chromosome 14 were most common. 37 patients (88.1%) had previously been exposed to immunomodulatory agents (IMiDs). 53.3% patients (n=24) were in first remission at RIC-HSCT, whilst 37.8% (n=17) were in second remission. 31.1% (n=14) of RIC-HSCTs were performed after second auto-HSCT following previous relapse and re-induction chemotherapy. 34 patients (55.9%) had achieved at least a very good partial response (VGPR) prior to RIC-HSCT. RIC-HSCT was performed a median of 20 months (range 10-89) from diagnosis. Two patients (4.8%) required re-transplantation for failed engraftment, but subsequently engrafted following in vivo T cell-depleting regimens.Mortality at early and interim time-points was low relative to registry and trial series, with TRM of 2.4% (n =1) and 9.5% (n=4) at day 100 and 365, respectively. 37 patients (82.2%) experienced chronic graft-versus-host disease (GVHD). Chronic skin GVHD was observed in 21 patients (grade 1-2: n=20; grade 3-4: n=1); chronic gastrointestinal GVHD in four patients (grade 1-2: n=1; grade 3-4: n=3); chronic hepatic GVHD in six patients (grade 1-2: n=4; grade 3-4: n=2); chronic oral GVHD in 17 patients (grade 1-2: n=17); and chronic ophthalmic GVHD in five patients (grade 1-2: n=5). There was an association between GVHD and enhanced disease control, as complete response rates increased from 26.5% to 51.5% by day 100 post-RIC-HSCT. However, 22 patients (48.9%) eventually relapsed with a median time to relapse of 6.5 months. 13 patients remain in CR one year post-RIC-HSCT. Relapse was treated with escalating donor lymphocyte infusions (DLI, n=13) or IMiDs (n=16). Response to lenalidomide at relapse was potentiated, despite the majority of patients having prior exposure to IMiDs. The median length of follow-up from diagnosis was 27 months (range 1-90). Median overall survival (OS) has not been reached; OS at two years was 69.2% (Figure 1).Conclusions: In this retrospective series we demonstrate the feasibility of Seattle-conditioned RIC-HSCT in multiple myeloma. We observed a very low early TRM of 9.5% and presence of allo-immune disease control (graft-versus-myeloma effect), thereby augmenting IMiD efficacy. Chronic GVHD was prevalent and relapse occurred in a significant proportion of patients, but salvage with DLI and IMiDs highlighted the efficacy of the graft-versus-myeloma effect elicited by RIC-HSCT. [Display omitted] DisclosuresCavet:Celgene: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees; Celgene: Other: Speaker. Tholouli:Pfizer: Honoraria, Speakers Bureau; MSD: Honoraria, Speakers Bureau; Jazz Pharmaceuticals: Honoraria, Speakers Bureau. Gibbs:Celgene: Honoraria; Takeda: Membership on an entity's Board of Directors or advisory committees; BMS: Membership on an entity's Board of Directors or advisory committees.

Differential Effects of Gut-Homing Molecules CC Chemokine Receptor 9 and Integrin-β7 during Acute Graft-versus-Host Disease of the Liver.

Homing of allogeneic donor T cells to recipient tissue is imperative for the development of acute graft-versus-host disease (GVHD) after bone marrow transplantation (BMT). In this study we show that alteration of T cell homing due to integrin-β7 deficiency on T cells or its ligand MAdCAM-1 in BMT recipients contributes to the pathophysiology of experimental GVHD. In contrast, lack of CC chemokine receptor 9 on donor T cells alters tissue homing but does not impact GVHD survival. We further demonstrate that MAdCAM-1 is aberrantly expressed in hepatic murine GVHD as well as in patients with active liver GVHD. However, infiltration of donor T cells in gut but not liver was dependent of MAdCAM-1 expression, indicating, that homing and/or retention of donor T cells rests on divergent molecular pathways depending on the GVHD target tissue.

Severe fludarabine neurotoxicity after reduced intensity conditioning regimen to allogeneic hematopoietic stem cell transplantation: a case report

Key Clinical MessageWe present a case of severe, irreversible neurotoxicity in a 55-year-old-patient with myelofibrosis undergoing hematopoietic stem cell transplantation following a reduced intensity conditioning including fludarabine. The patient developed progressive sensory-motor, visual and consciousness disturbances, eventually leading to death. MRI imaging pattern was unique and attributable to fludarabine neurotoxicity.

Single-Agent High-Dose Cyclophosphamide for Graft-versus-Host Disease Prophylaxis in Human Leukocyte Antigen–Matched Reduced-Intensity Peripheral Blood Stem Cell Transplantation Results in an Unacceptably High Rate of Severe Acute Graft-versus-Host Disease

High-dose cyclophosphamide given early after allogeneic hemopoietic cell transplantation has been shown to be effective prophylaxis against graft-versus-host disease (GVHD) in the setting of HLA-matched myeloablative bone marrow grafts, allowing avoidance of long-term immunosuppression with calcineurin inhibitors in some patients. Whether this approach is feasible using granulocyte colony–stimulating factor (G-CSF)–mobilized peripheral blood stem cell grafts is unknown. We conducted an exploratory phase 2 trial of cyclophosphamide given at 50 mg/kg i.v. on days 3 and 4 after transplantation as sole GVHD prophylaxis in recipients of G-CSF–mobilized peripheral blood stem cell grafts from HLA-matched related or unrelated donors after reduced-intensity conditioning therapy with fludarabine, carmustine, and melphalan. Five patients, ages 52 to 67 years, with high-risk hematologic malignancies were enrolled. Four of the 5 developed severe acute GVHD of grades 3 to 4, requiring treatment with methylprednisolone and cyclosporine; 3 were steroid refractory and were given salvage therapy. One of these 4 patients died of hepatic GVHD, one died of sepsis, and 2 survived. We conclude that post-transplantation cyclophosphamide is inadequate as sole GVHD prophylaxis in the context of peripheral blood reduced-intensity conditioning transplantations from HLA-matched donors. This trial is registered at ACTRN12613001154796.

Attenuation of Hepatic Graft-versus-host Disease in Allogeneic Recipients of MyD88-deficient Donor Bone Marrow.

Acute graft-versus-host-disease (GVHD) is characterized by selective damage to the liver, the skin, and the gastrointestinal tract. Following allogeneic hematopoietic stem cell transplantation, donor bone marrow (BM) cells repopulate the immune system of the recipient. We previously demonstrated that the acute intestinal GVHD (iGVHD) mortality rate was higher in MyD88-deficient BM recipients than that in the control BM recipients. In the present study, the role of MyD88 (expressed by donor BM) in the pathophysiology of hepatic GVHD (hGVHD) was examined. Unlike iGVHD, transplantation with MyD88-deficient T-cell depleted (TCD) BM attenuated hGVHD severity and was associated with low infiltration of T cells into the liver of the recipients. Moreover, GVHD hosts, transplanted with MyD88-deficient TCD BM, exhibited markedly reduced expansion of CD11b+Gr-1+ myeloid-derived suppressor cells (MDSC) in the liver. Adoptive injection of the MDSC from wild type mice, but not MyD88-deficient mice, enhanced hepatic T cell infiltration in the MyD88-deficient TCD BM recipients. Pre-treatment of BM donors with LPS increased MDSC levels in the liver of allogeneic wild type BM recipients. In conclusion, hGVHD and iGVHD may occur through various mechanisms based on the presence of MyD88 in the non-T cell compartment of the allograft.

Deviated balance between Th1 and Th17 cells exacerbates acute graft-versus-host disease in mice

BackgroundTh1/Th17 imbalance had been indicated to mediate several kinds of inflammatory diseases. We deduce that Th1/Th17 imbalance might also contribute to the pathogenesis of acute graft-versus-host disease (GVHD). This study is to investigate the relation between Th1/Th17 imbalance and acute GVHD. MethodsWe applied a murine GVHD model of C57BL/6 (H-2b) donor to BALB/c (H-2d) recipient by treating the recipients with low dose of halofuginone (HF), which is competent in selectively inhibiting Th17 differentiation and facilitating Th1 differentiation. Recipient mice were monitored for survival rate, body weight change, clinical symptoms and pathological evidence of acute GVHD. We also measured the proportions of Th1 and Th17 cells in circulation and expression levels of IFN-γ and IL-17A in tissues involved in GVHD. ResultsFirstly, we confirm the existence of Th1/Th17 imbalance in acute GVHD and Th1/Th17 imbalance positively correlates with severity of acute GVHD. Secondly, low dose of HF augments Th1/Th17 imbalance by driving the Th1/Th17 balance to a Th1-dominant reaction. Finally, augmented Th1/Th17 imbalance leads to aggravated systemic GVHD. An increased Th1-type reaction results in aggravated hepatic and intestinal GVHD, and inhibiting Th17 differentiation is sufficient to alleviate pulmonic impairment. ConclusionOur study is indicative for a critical role of Th1/Th17 imbalance in the pathogenesis of murine GVHD.

Thiol/Redox Metabolomic Profiling Implicates GSH Dysregulation in Early Experimental Graft versus Host Disease (GVHD)

Graft-versus-host disease (GVHD) is a common complication of allogeneic bone marrow transplantation (BMT). Upregulation of inflammatory cytokines precedes the clinical presentation of GVHD and predicts its severity. In this report, thiol/redox metabolomics was used to identify metabolic perturbations associated with early preclinical (Day+4) and clinical (Day+10) stages of GVHD by comparing effects in Syngeneic (Syn; major histocompatibility complex- identical) and allogeneic transplant recipients (Allo BMT) in experimental models. While most metabolic changes were similar in both groups, plasma glutathione (GSH) was significantly decreased, and GSH disulfide (GSSG) was increased after allogeneic compared to syngeneic recipient and non-transplant controls. The early oxidation of the plasma GSH/GSSG redox couple was also observed irrespective of radiation conditioning treatment and was accompanied by significant rise in hepatic protein oxidative damage and ROS generation. Despite a significant rise in oxidative stress, compensatory increase in hepatic GSH synthesis was absent following Allo BMT. Early shifts in hepatic oxidative stress and plasma GSH loss preceded a statistically significant rise in TNF-α. To identify metabolomic biomarkers of hepatic GVHD injury, plasma metabolite concentrations analyzed at Day+10 were correlated with hepatic organ injury. GSSG (oxidized GSH) and β-alanine, were positively correlated, and plasma GSH cysteinylglycine, and branched chain amino acids were inversely correlated with hepatic injury. Although changes in plasma concentrations of cysteine, cystathionine (GSH precursors) and cysteinylglycine (a GSH catabolite) were not significant by univariate analysis, principal component analysis (PCA) indicated that accumulation of these metabolites after Allo BMT contributed significantly to early GVHD in contrast to Syn BMT. In conclusion, thiol/redox metabolomic profiling implicates that early dysregulation of host hepatic GSH metabolism and oxidative stress in sub-clinical GVHD before elevated TNF-α levels is associated with GVHD pathogenesis. Future studies will probe the mechanisms for these changes and examine the potential of antioxidant intervention strategies to modulate GVHD.