Hepatic GVHD Research Articles

GVHD targets organoid-forming bile duct stem cells in a TGF-β–dependent manner

AbstractGraft-versus-host disease (GVHD) is a major life-threatening complication that occurs after allogeneic hematopoietic cell transplantation (HCT). Although adult tissue stem cells have been identified as targets of GVHD in the skin and gut, their role in hepatic GVHD is yet to be clarified. In the current study, we explored the fate of bile duct stem cells (BDSCs), capable of generating liver organoids in vitro, during hepatic GVHD after allogeneic HCT. We observed a significant expansion of biliary epithelial cells (BECs) on injury early after allogeneic HCT. Organoid-forming efficiency from the bile duct was also significantly increased early after allogeneic HCT. Subsequently, the organoid-forming efficiency from bile ducts was markedly decreased in association with the reduction of BECs and the elevation of plasma concentrations of bilirubin, suggesting that GVHD targets BDSCs and impairs the resilience of BECs. The growth of liver organoids in the presence of liver-infiltrating mononuclear cells from allogeneic recipients, but not from syngeneic recipients, was significantly reduced in a transforming growth factor-β (TGF-β)–dependent manner. Administration of SB-431542, an inhibitor of TGF-β signaling, from day 14 to day 28, protected organoid-forming BDSCs against GVHD and mitigated biliary dysfunction after allogeneic HCT, suggesting that BDSCs are a promising therapeutic target for hepatic GVHD.

Dosage, Safety and Efficacy of Posaconazole As Primary Antifungal Prophylaxis in High-Risk Recipients of Allogeneic Stem Cell Transplantation

Introduction: The use of anti-mold prophylaxis with anti-aspergillus activity is recommended for patients (pts) undergoing allogeneic hematopoietic stem cell transplantation (Allo-HSCT) with high risk of fungal infection (Maertens, J Antimicrob Chemother 2018). Yet, few data are available regarding the use of posaconazole. Methods: This retrospective study included all Allo-HSCT adult recipients having benefited from posaconazole therapy in our center as a primary anti-fungal prophylaxis for high-risk of fungal infection. The latter was defined as use of i)an alternative donor, ii)sequential conditioning regimen, iii)a regimen associated with severe mucositis, iv) post-transplant cyclophosphamide (PT-Cy) or v) previous allo-HSCT. Posaconazole was programmed to be initiated at day (D) 0 or D5/6 (in case of PT-Cy) and administered up to day 100. We report here on the residual concentration of posaconazole during the neutropenic phase then on the tolerance and efficacy of such prophylaxis in this cohort. Results: Seventy high-risk pts (males 63.3%, median age 54 years old, range 20-73) received Allo-HSCT between April 2020 and December 2021 for a myeloid (n=51), lymphoid (n=17) or non-malignant hematological (n=2) disease and received posaconazole as a primary prophylaxis. The Sorror score at transplant time was ≥ 3 for 24 pts (33.8%). Twenty-two patients had already received posaconazole as a primary prophylaxis before Allo-SCT including 26 during the neutropenic phase of their induction for AML or MDS, 3 for prolonged neutropenia, 2 during treatment with alemtuzumab for T-cell leukemia/lymphoma, and 1 during a previous AlloHCST. Four patients had also received other antifungal agentsbefore Allo-SCT (caspofongine (n=1), voriconazole (n=1) or liposomal amphotericin B (n=2)) because of a suspected mold infection which has been finally excluded. All pts had at least one high-risk criterion of fungal infection. These included the use of an alternative donor in 42 pts (haplo-identical donor n= 41, umbilical cord blood n=1), sequential conditioning regimen in 9, with PT-Cy in 57, second or third allo-HSCT in 8 and conditioning regimen associated with severe mucositis in 11 (TBI 8-12gy n=3, thiotepa-based n=8). All but one pts received posaconazole using the gastroresistant tablet form at a dose of 300mg/day. One patient received the drinkable suspension form at a dose of 200mg 3 times a day. Following prophylaxis initiation, serum posaconazole concentrations were available in 51 and 16 patients at medians of 9 and 39 days, respectively. A protective residual level of posaconazole (> 0.5mg/L) was achieved in 57% of the patients (n=29) at first assessment and 87.5% (n=12) at second evaluation. Posaconazole was stopped early due to related-toxicity in 9 cases (12.6%), including liver toxicity in 7 pts, QT prolongation in 1 and skin hyperesthesia in 1. Treatment was restarted without recurrence of toxicity in 2 cases. Posaconazole was stopped early in 2 patients due to non-related toxicity, including one veno-occlusive disease and one hepatic acute GVHD. Posaconazole was temporary discontinued in 4 patients due to a suspected fungal infection before being restarted. Most patients (n=59/70, 84.2%) did not present fungal infections while being under posaconazole therapy. Only 11 cases were documented with this complication (Table 1), including 8 invasive pulmonary aspergillosis (IPA; possible n=3; probable n=5), one possible invasive fungal infection and 2 mucormycoses (1 with possible IPA). Fungal infections occurred despite documentation of a protective residual level of posaconazole (> 0.5mg/L) in 5 of 6 evaluable patients. Of note, 9/11 patients had received PTCY as GVHD prophylaxis. Posaconazole was stopped (before D7 in 3) and other antifungal drugs started (voriconazole or liposomal amphotericin B) allowing to fungal infection cure in 5 pts. However, 7 pts died including 2 of an uncontrolled fungal infection. Conclusion: Posaconazole is a well-tolerated and efficient primary prophylaxis in recipients of Allo-HSCT at high-risk of fungal infection. As some fungal infections occured very early after D0 while prophylaxis started only a D5/6 after PTCY, our results suggests to propose posaconazole as early as the beginning of the conditionning together with dose monitoring. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Characterization of Hepatic Dysfunction in Subjects Diagnosed With Chronic GVHD by NIH Consensus Criteria

Hepatic chronic graft-versus-host disease (cGVHD) causes morbidity and current diagnostic criteria are nonspecific. An accurate diagnosis is imperative because overdiagnosis can lead to unnecessary treatment with immunosuppressive agents and raising the risk of opportunistic infections. We aim to characterize different patterns of liver injury and cytokine profiles associated with hepatic dysfunction in cGVHD, to evaluate the accuracy of the NIH Consensus Criteria (NCC) for hepatic cGVHD and to explore predictors for hepatic cGHVD. Patients were evaluated in this prospective cross-sectional study of patients with cGVHD recruited under a natural history protocol. Laboratory tests and cytokines were measured. The cGVHD were diagnosed and scored based on NCC. Clinically indicated liver biopsy specimens or autopsies were reviewed by an expert hepatopathologist (D.E.K.). Comparisons were made between groups, and univariable and multivariable logistic regression were calculated. Of the 302 patients enrolled, 151 fulfilled hepatic cGVHD based on NCC; however, 69% had at least 1 abnormal liver test result. Abnormal alanine aminotransferase (ALT) and aspartate aminotransferase were associated with lower platelets, higher total bilirubin (TB), total cholesterol, serum amyloid A, and IL 15. Abnormal ALP and gamma-glutamyl transpeptidase were associated with higher cholesterol, and IL7. Lower platelet count was associated with higher ALT, TB, and triglycerides and lower albumin. Of the 27 with liver tissue, 16 had histologic features of GVHD, only eight met clinical criteria for hepatic GVHD. Sensitivity and specificity of NCC in identifying hepatic GVHD were 50% and 27% (Kappa=-0.23). Only 6 had only hepatic GVHD, whereas 10 had hepatic GVHD with either iron overload, nodular regenerative hyperplasia, or steatosis. Multivariable logistic regression showed that ALP and total cholesterol were associated with hepatic GVHD and total cholesterol >220 mg/dL increased the sensitivity for histologic hepatic GVHD. In conclusion, abnormal liver enzymes in cGVHD are nonspecific and have poor correlation with histologic evidence for hepatic GVHD, highlighting the importance of histology. Cytokines provide insight into the pathogenesis of hepatic cGVHD. Decreased platelet count was associated with factors associated with liver disease including portal vein diameter, which may suggest progression of liver disease. This highlights the need of incorporating these factors in natural history study and using liver biopsy to understand the development of liver dysfunction in hematopoietic stem cell transplantation and to develop better instruments to decreased hepatic cGVHD related morbidity and mortality. The study was registered with a ClinicalTrials.gov identifier NCT00092235.

Clinical Implications Of Severe Isolated Hepatic Gvhd Post-DLI

BackgroundDonor lymphocyte transfusion (DLI) may induce the graft-versus-leukemia (GVL) effect, but may also increase the risk of graft-versus-host disease (GVHD). Thus, the escalating-dose DLI and/or co-administration with short-term immunosuppressive agents are one of the clinical strategies to keep the balance between GVHD / GVL nowadays. AimsHere we review the clinical manifestation of GVHD post–DLI, and discuss its clinical implication. Patients and MethodsIn this retrospective study, 15 consecutive patients in high risk underwent 41 times DLI after the transplantation for acute myeloid leukemia, acute lymphoid leukemia, chronic myeloid leukemia, myelodysplastic syndrome and lymphoma since 2009 are studied. The median age of patients was 33 years (range 8 to 51 years). All patients have an HLA-identical sibling donor and achieved full donor chimerism soon after the myelosuppressive conditioning. DLI were used regularly in escalating-dose and co-administration with short-term immunosuppressive agents (low dose cyclosporine A and methylprednisolone). Except 1 case received DLI in combination with low-dose cytarabine for the treatment of relapsed AML, all the other cases were given pre-emptive DLI 4 months after the transplantation. All cases initially have no clinical signs of liver damage, acute and/or chronic GVHD, and severe infection. After viral hepatitis and recent drug exposure are excluded, the possible relationship between correlation between the liver dysfunction and the clinical features of GVHD are evaluated. Results8 out of 15 cases developed GVHD post-DLI, of whom 3 had isolated liver involvement after the first infusion, and 5 had a limited skin rash and liver involvement after the second or third infusion. Liver function tests showed the elevated aminotransferases with hyperbilirubinemia in 3 cases with isolated liver involvement, but without hyperbilirubinemia in the other 5 cases. Serum gamma-glutamyltransferas(GGT) was persistently elevated in all these 8 cases, and the peak levels of which in all 3 cases with isolated liver involvement were 30-50 times of the normal upper limit, while a slight elevation in the other 5 cases. After the viral hepatitis and recent drug exposure were excluded, liver biopsy was then performed and revealed lymphocytic infiltration of the portal tracts and vacuolization of the biliary epithelial cells. There were also pictures of the loss of bile ducts and increased fibrosis, which was compatible with the diagnosis of GVHD of cholangiohepatitic type. 3 cases with severe hepatic GVHD were finally died of the progression of GVHD in 7 months (1 case) or disease relapse (2 cases) in 1-2 years. All the other 5 cases are still alive with the disease-free survival of 38 months. ConclusionThe findings indicate that isolated hepatic GVHD might be a distinct clinical feature in DLI, which is different to the classic GVHD post transplantation. Persistent Elevation of GGT might serve as a marker of hepatic GvHD post-DLI. Furthermore, how to balance of GVHD and GVL is very complex, while the prevention of GVHD would be associated with the loss of immune reconstitution and GVL. Disclosures:No relevant conflicts of interest to declare.

Liver disease during and after hematopoietic stem cell transplantation in adults: a single-center Egyptian experience

BackgroundHepatic complications are a well-known cause of both early and late mortality and morbidity in hematopoietic stem cell transplant (HSCT) recipients. Early diagnosis and management of hepatic complications is important in order to commence appropriate therapy. Conditioning regimens, acute and chronic graft versus host disease, sinusoidal obstruction syndrome, and infections among others represent major hepatic complications for the transplant recipient. We assessed liver function tests, viral markers, polymerase chain reaction, abdominal ultrasound, portal, and hepatic venous duplex in 88 patients underwent autologous and 102 patients underwent allogeneic transplant as well as liver biopsy in selected patients in this retrospective study and evaluated early and late hepatic complications and their impact on transplant outcome.ResultsThe major cause of hepatic injury in allogeneic patients is the conditioning regimen (38.8%) followed by acute GVHD (14.7%), after day +100 chronic hepatic GVHD is the primary cause of liver injury which occurred in about 40% of allogeneic patients. In autologous patients, the first cause of hepatotoxicity is also conditioning regimen involving 27.9% of patients followed by flare of viral hepatitis in 7.9% and sepsis in 6.3% of cases. The prevalence of HCV, HBV, and CMV is 19%, 16%, and 8%, respectively.ConclusionIn our study, conditioning regimens, acute and chronic hepatic GVHD are frequent causes of hepatic injury following allogeneic HSCT while conditioning regimens, flare of viral hepatitis, and sepsis represent the most common causes of hepatic injury following autologous HSCT.

Circulating Endothelial Cells As a Marker of Vascular Injury in Pediatric Patients

<h3>Introduction</h3> Thrombotic microangiopathy (TMA), hepatic veno-occlusive disease (VOD) and GVHD are major causes of morbidity and mortality in hematopoietic stem cell transplant (HSCT) recipients. Current strategies to identify these complications involve surveilling markers of immune activation and organ function. Unfortunately, these processes are frequently identified after organ damage has occurred, creating the need for a timelier marker of disease. Circulating endothelial cells (CECs) have been shown to directly reflect vascular injury and are a potential tool for identifying early evidence of endothelial damage. Our study quantifies and characterize CECs in pediatric patients undergoing HSCT and aims to identify the timing of peak vascular injury relative to transplant as well as the relationship between CECs and post-transplant vascular complications. <h3>Methods</h3> CEC analysis was performed prior to and after stem cell infusion. All patients had central venous catheters. CEC identification was done on whole blood using Invitrogen M-450 Tosylactivated Dynabeads coupled to a CD146 antibody. Confirmatory staining after immunomagnetic isolation was done using acridine orange and propidium iodide (AOPI). CEC identification criteria are shown in Figure 1. Two reviewers quantified CECs by morphology and bead number. Negative controls were done using healthy donor blood. <h3>Results</h3> CEC testing was done on 8 HSCT patients (Fanconi Anemia=1, AML=2, ALL=2, ICF-1 syndrome=1, Hemoglobin Hammersmith=1 and macrophage activation syndrome=1). 6 conditioning regimens were myeloablative and 2 were reduced intensity. CEC quantification for individual patients is shown in Figure 2. The vast majority of patients (n=7) had a peak CEC value prior to day 14, including 4 patients whose peak value occurred prior to stem cell infusion. Clinical complications are described in Figure 2. The two highest CEC values recorded were in patients with severe complications, including cardiac arrest (Patient 5, 124 CECs/mL) and death (Patient 7, 84 CECs/mL). The individual difference between lowest recorded CEC value and peak CEC value was also greatest in these patients (Patient 5, 120 CECs/mL; Patient 7, 80 CECs/mL). Mean CEC values for HSCT patients and controls are shown in Figure 3. <h3>Conclusion</h3> CECs reliably peaked within the first 2 weeks of HSCT suggesting marked vascular injury occurs in this timeframe. CEC count peaked prior to stem cell infusion in half of these patients, which implies a large component of vascular injury is driven by the conditioning process. As predicted, the highest CEC values recorded were in patients with grave complications, including one patient who died from multiorgan system failure. Continued data collection will be informative as to whether the nature of these peaks or characteristics of the CECs themselves will predict future vascular complications.

PB2220 SURVIVAL OUTCOME OF HIGH‐RISK PATIENTS WITH MYELOFIBROSIS TREATED WITH ALLOGENEIC HEMATOPOIETIC CELL TRANSPLANTATION FOLLOWING REDUCED‐INTENSITY CONDITIONING REGIMENS

Background:Allogeneic hematopoietic cell transplantation (allo‐HCT) is the only curative treatment for myelofibrosis (MF), but substantial risk of transplantation‐related mortality (TRM) is a considerable obstacle especially in elderly patients or in patients with severe comorbidity. In the era of Janus kinase (JAK) inhibitors, transplantation may be delayed in good responders but cytopenia is a major complication, and we confront refractory patients who should be treated with allo‐HCT immediately.Aims:Here, we are going to show our experiences on high‐risk MF patients who were treated with reduced‐intensity conditioning (RIC) allo‐HCT.Methods:Here, we are going to show our experiences on high‐risk MF patients who were treated with reduced‐intensity conditioning (RIC) allo‐HCT.Results:All showed successful engraftment. Including 2 patients who were conditioned with nonmyeloablative regimen, total 6 (15.8%) showed delayed graft failure at a median 8 months post‐HCT (range, 3.8‐13.8). Two recovered after stem cell booster from the same donor, other 2 received donor lymphocyte infusion but showed progression, and 1 died after 2nd allo‐HCT. Among the 33 patients with post‐HCT bone marrow (BM) exam results, 29 (87.8%) showed significant improvement of BM fibrosis (range, 14‐661 days). After median follow‐up duration of 24.6 months (range, 6.1‐124.8), 2‐year OS was 64.6% (64.3% in triple‐negative subgroup), 2‐year nonrelapse mortality was 27.4%, and 2‐year graft‐and‐relapse‐free survival (GRFS) was 28.4%, which suggested there were fatal high‐grade GVHD in this cohort. Acute GVHD was observed in 18 patients (5 grade II, 7 grade III, 4 grade IV) and a cumulative incidence of grade III‐IV acute GVHD was 30.6%. Chronic GVHD was observed in 13 (4 mild, 2 moderate, 7 severe), and a cumulative incidence of severe chronic GVHD was 27.5%. Among them, severe hepatic GVHD was observed in 9 patients (5 acute, 4 chronic). Among 11 dead patients, 7 died due to fatal hepatic GVHD, 1 died of lung GVHD, and 3 died due to septic pneumonia. Multivariate analysis revealed 2‐year OS was significantly poorer in patients who suffered from hepatic GVHD (HR = 9.8, 95%CI 1.0‐94.7, p = 0.022) and the significant cause of fatal hepatic GVHD was unrelated or mismatched donor HCT.Summary/Conclusion:RIC allo‐HCT can be a valid choice providing graft‐versus‐myelofibrosis effect for advanced and triple‐negative MF patients, but fatal hepatic GVHD was frequently observed especially in unrelated or mismatched donor transplants which should be overcome in the future.

PB2382 FOLLOW UP POST ALLOGENIC STEM CELL TRANSPLANTATION IN MOROCCO: ABOUT 28 PATIENTS

Background:Allogenic hematpoetic stem cell transplantation is a cure for hematological malignancies and certain of immune system diseases,but is associated with high morbidity due to immunological reaction between donor and recipient:Graft versus host diseaseAims:repport our experience in management of post allograft complicationsMethods:this is a retrospective descriptive study,between 2007 and 2018,including 28patientsThe follow up was done in the clinical departement of hematology of Rabat,but allograft was performed in Percy military hospital in ParisResults:In this study, spread between 2007 and 2018, all patients included were sent to the Percy military hospital for an allograft of hematopoietic stem cells between 2007 and 2018, the median age was 32 years (15 years and 60 years), 55% were male, 17 patients were followed for acute leukemias including 09 myeloid type, 04 myeloproliferative neoplasms (01 CML, 03PMF), 03 patients for aplastic anemia, 01 MDS, 03 patients for lympho‐proliferative syndrome (01 Hodgkin's lymphoma, T lymphoma and multiple myeloma). The duration between diagnosis and bone marrow transplant was around 12 months (2 months and 6 years), 75% of patients were transplanted from a geno‐identical donor, 17% from a 10/10 pheno‐identical voluntary donor, while one patient received a haplo‐identical transplant and another a transplant of placental blood units. A peripheral stem cell graft was used in 75% of patients, several conditioning regimens were used, including: Busulfan / Endoxan in 30% (acute leukemias) Fludarabine‐Busulfan‐thymoglobulin in 28%. Anti‐GVHD prophylaxis was done by Methotrexate / ciclosporin in 58% of cases, ciclosporin alone in 22% and ciclosporin‐mycophenolate mofetil in 18% of cases. The immediate consequences of the graft were marked by the occurrence of bacterial infections in 71%, the reactivation of CMV in 9 patients, acute GVH was found in 38% of patients, cutaneous type with a good response to corticosteroids. During our follow‐up, 35% of patients showed signs of chronic GVH ‐with 35% of patients who had acute GVH. All types was present:cutaneous and oral (71%), pulmonary (58%), ocular (58%), hepatic (28%), muscular (28%), digestive and gynecologic GVHD. (14%), immunosuppressive treatments (ciclosporin) and corticosteroids were used in the first line in all patients with a response less than 30%. In the second line, Rituximab was used in 71% of patients, ITK (Imatinib) in 28% (pulmonary GVH), and extracorporeal photophoresis in a patient with musculoskeletal GVHD.The median follow‐up was 45 months with an overall survival of 67% and an event‐free survival of 60%.Summary/Conclusion:Allogenic stem cell transplantation is a real challenge in under‐developing countries, The post‐transplant represent a heavy multidisciplinary approach and a very expensiveIn our series 10% of patients have died from chronic GVH, then we need a better understanding and mastery of this complication.

Allogeneic Hematopoietic Cell Transplantation for Severe Idiopathic Aplastic Anemia Older Than 40y

▪Upfront allogeneic hematopoietic cell transplantation (alloHCT) as first line therapy for older than 40 or 50 years is not usually recommended for severe aplastic anemia patients even though there are suitable matched sibling donors because they usually have poor outcomes after alloHCT. Therefore, first line immune suppression therapy (IST) is recommended. However, current outstanding alloHCT outcome can make it possible to try upfront alloHCT even in older AA patients. The purpose of this retrospective study is to determine the transplantation-related results in AA patients older than 40 years. This study collected data retrospectively for older AA patients. Congenital bone marrow failure was excluded from this study. alloHCT was divided as upfront and second alloHCT according to prior IST.Total 129 patients were enrolled in this study from 2001 to 2017. Age at diagnosis and at alloHCT were 25 to 63 (median 48.0) years and 40.3-64.9 (median 49.1) years, respectively. Median time from diagnosis to alloHCT was 5.2 (range, 1-234.1) months. Upfront and second alloHCT were 42 and 87 patients, respectively. Upfront alloHCT received more stem cells from related donors, more BM stem cells and more fludarabine conditioning compared with second alloHCT (83.3% vs. 58.6%, p=0.005; 52.4% vs. 74.7%, p=0.011; 52.4% vs. 30.2%, p=0.015, respectively). However, ABO mismatching (p=0.747), TBI conditioning (p=0.547), cyclophosphamide conditioning (p=0.114), ATG conditioning (p=0.483) were similar between upfront and second alloHCT. Any engraftment failure, neutrophil engraftment failure and platelet engraftment failure were similar between upfront and second alloHCT (28.6% vs. 28.7%, p=0.985; 19.0% vs. 18.4%, p=0.928; 19.0% vs. 34.5%, p=0.072). Hepatic SOS, acute GvHD and chronic GvHD were also similar between upfront and second alloHCT (4.8% vs. 5.7%, p=0.817; 28.6% vs. 36.5%, p=0.376; 19.0% vs. 19.5%, p=0.947). Survival rates at 1Y, 2Y, 3Y and 5Y were 90.7, 82.2, 73.5 and 64.3%, respectively. Survival rates at 5 years in upfront and second alloHCT were 76.2 and 54.1%, respectively (p=0.059). Survival rates at 5 years (5YSR) in age 40-50y, 50-60y, and older than 60y were 64.1, 62.4 and 50.0%, respectively (p=0.349). alloHCT from matched related donor or other donors had similar survival rates (p=0.404). However, upfront alloHCT showed superior survival rate (5YSR 76.5% vs. 53.2%, p=0.114) without statistical significance compared with second alloHCT even in matched related donor subgroup. This trend is similar in alternative donor subgroup (5YSR 75.0% in upfront alloHCT vs. 54.9% in second alloHCT, p=0.459).alloHCT in older AA showed promising results even in patient older than 60 years although upfront alloHCT showed marginal statistical superiority. In conclusion, upfront alloHCT in older AA needs further confirmation by prospective studies. DisclosuresNo relevant conflicts of interest to declare.

Risk Factors and Prognosis of Hepatic cGVHD after Allogeneic Hematopoietic Stem Cell Transplantation

To analyze the risk factors and prognosis of hepatic chronic GVHD after allogeneic hematopoietic stem cell transplantation (allo-HSCT). The clinical data of 147 patients undergoing allo-HSCT from January 2013 to December 2016 were analyzed, the correlation between recipient age and sex, disease state, matched degree of HLA, donor sex, stem cell sources, ATG in GVHD prophylaxis, liver dysfunction during conditioning period, pre-transplant HBsAg, prior aGVHD and hepatic cGVHD were studied, and the correlation between hepatic cGVHD and prognosis were analysed. Thirty-two patients had hepatic cGVHD, cumulative incidence of 26.4%. In univariate analysis, pre-transplant HBsAg+and liver dysfunction during conditioning period were not significantly related with hepatic cGVHD (P>0.05). In multivariate analysis, prior acute GVHD (HR=2.087, P=0.045) was the independent risk factor for hepatic cGVHD, ATG (HR=0.231, P=0.000) was significantly related with a lower incidence of hepatic cGVHD. In univariate analysis, patients with hepatic cGVHD had a lower 2 years relapse rate (P=0.038). Prior acute GVHD is the independent risk factor for hepatic cGVHD, the ATG can significantly reduce the incidence of hepatic cGVHD. Hepatic cGVHD has been found to relate with a lower 2 years relapse rate.

De novo recipient-specific Glutathione S-transferase T1 antibody development after HLA-identical hematopoietic cell transplantation

Donor-specific antibodies against Glutathione S-transferase T1 (GSTT1) have been associated with de novo immune hepatitis after liver transplantation. These antibodies have also been found very early in allo-HCT associated with acute hepatic GvHD but in all the cases the donor cells had experienced previous priming through pregnancies. It remained to be explored whether or not primary recognition of the antigen occurs after HCT and what could be the consequences in the long term outcome. We genotyped a cohort of 68 HCT patients and found 11 with the GSTT1 null donor/positive recipient mismatch. After testing 114 serum samples, we found a unique case of a 33-year-old patient transplanted from his HLA-identical sibling donor in which IgG GSTT1 antibodies were detected for the first time on day +178. After stimulation of peripheral blood mononuclear cells with GSTT1 peptides we could demonstrate that this patient also had GSTT1-specific T lymphocytes that became activated upon exposure to the GSTT1 antigen. In this report, we describe the first case in which simultaneous T and B cell response against GSTT1 is developed in HCT although the clinical consequences in GvHD are still unclear.

Prevalence, Risk Factors, and Outcomes of Bronchiolitis Obliterans After Allogeneic Hematopoietic Stem Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (HSCT) is a therapeutic approach for malignant and nonmalignant hematological disorders. Survival rates increased after allogeneic HSCT, and therefore, late transplant-related complications have become more frequent. We retrospectively analyzed the incidence, risk factors, and outcome of obliterative bronchiolitis. Between January 2000 and November 2012, 89 transplanted pediatric patients were retrospectively evaluated. The diagnosis of bronchiolitis obliterans was made according to the NIH consensus criteria for chronic graft-versus-host disease (cGVHD). Univariate and multivariate analysis was conducted on the following risk factors: age at HSCT, sex, high risk, type of donor and type of diagnosis, conditioning regimen, total body irradiation, busulfan-based regimen, acute and cGVHD, donor sources, ABO blood group incompatibility, Rh incompatibility, human leukocyte antigen (HLA), and cytomegalovirus (CMV) reactivation. Seven patients met the diagnostic criteria. The prevalence was 7.8%. Pulmonary function tests (PFTs) performed in all bronchiolitis obliterans (BO) patients did not present any abnormality. PFT variables decreased significantly. Four patients presented with moderate forms of obliterative bronchiolitis, 1 patient was identified as having mild form, and 2 patients were categorized with severe obliterative bronchiolitis. cGVHD, both in hepatic and cutaneous form, was demonstrated in the present study to be a major risk factor. The higher incidence of bronchiolitis obliterans in children with hepatic and cutaneous GVHD could be potentially interpreted on the basis that cGVHD is an immunoregulatory disorder that involves almost any organ of the body, and therefore, BO could be described as the pulmonary manifestation of a systemic disease.

Mesenchymal stromal cells: potential roles in graft‐versus‐host disease prophylaxis and treatment

Mesenchymal stromal cells: potential roles in graft‐versus‐host disease prophylaxis and treatment

Iron Overload in Patients Receiving Allogeneic Hematopoietic Stem Cell Transplantation

Iron overload has been associated to a variety of post-transplant complications, including infections, sinusoidal obstructive syndrome and it is conceivable that increased hepatic iron may mimic the clinical picture of GVHD or even may contribute to the worsening of hepatic GVHD. Objectives and Methods: aim of present review was to summarize the current knowledge about diagnosis and treatment strategies of iron overload following HSCT. Results: serum ferritin may be considered as surrogate marker of iron overload and is widely used as an indicator of body iron status; however other noninvasive diagnostic methods, namely SQUID and MRI, may provide more precise information on iron burden in specific organs, such as liver and heart. Since there are not physiological tools to remove efficiently the excess of iron, it is of particular importance to consider iron depleting therapy. Phlebotomy should be considered as the first line treatment of iron overload, while iron chelators, such as deferasirox, may represent an alternative option for patients with an inadequate hematological recovery. Discussion: additional prospective studies are mandatory to investigate the relationship between iron overload and the outcome of patients receiving an allogeneic stem cell transplantation.

English

A 25 years old gentleman presented with bleeding gums, purpura and fever for 2 months and severe anemia requiring 10 blood transfusions. Baseline hematological investigations and bone marrow examination confirmed aplastic anemia. He underwent allogeneic stem cell transplant as a curative option with HLA identical sister as the donor. Neutrophils engrafted on day +16. On day +115 he showed signs of dyshydrotic eczema and was initiated on local and systemic steroids and topical tacrolimus. As there were features of Cyclosporin induced MAHA, the same was stopped and oral Mycophenolate was initiated on day +129. On day +170 he presented with extensive progression of cutaneous and hepatic GVHD. Subsequent treatment with Cyclophosphamide, Sirolimus and Daclizumab did not show significant response. On day +195, he succumbed to sepsis with multiorgan failure. The diagnosis of ezcematoid GVHD was confirmed by cutaneous manifestations, biopsy, the clinical course and the presence of GVHD in other organs.

A prospective study of lenalidomide monotherapy for relapse after Allo-SCT for multiple myeloma

Allo-SCT can result in long-term remission in patients with multiple myeloma (MM), although its overall role in disease management remains controversial. We evaluated lenalidomide monotherapy response and tolerability among 18 patients with MM who progressed or relapsed after Allo-SCT, who were enrolled a median of 12 months (range 3-104) following transplant. Treatment duration of lenalidomide was 8 months (range 1-57). Ten patients required dose reductions from 25 to 5-20 mg at a median of three cycles (range 1-12): eight for neutropenia, one for thrombocytopenia and one for myalgias and weakness. Serious adverse events (N=5) included H1N1 influenza (2), bacterial pneumonia (2) and fever, myalgia and hypoxia. Two patients died at 3 and 5 months of gastrointestinal or hepatic GVHD occurring within 1 month of dosing. Responses included complete response (CR) (5), very good partial response (2), partial response (PR) (3), minimal response (1) and stable disease (2) for an overall response rate (≥ PR) of 56%. Ten patients discontinued therapy for progressive disease (PD) at a median of 8.5 (1-43) months. Six patients died from PD. Five patients remained on therapy at 39 months (range 14-57), with four in CR. Lenalidomide for relapse of MM after Allo-SCT can result in extended disease control (>12 months) in 50% of patients.

Hepatic GVHD leading to cirrhosis after allogeneic hematopoietic SCT

Hepatic GVHD leading to cirrhosis after allogeneic hematopoietic SCT

Autoimmune-Like Hepatitis Following Allogeneic Hematopietic Stem Cell Transplantation: Different Manifestation From Hepatic Graft-Versus-Host Disease

Abstract 4550 Background:Occasional cases of post-transplant liver dysfunction which resemble autoimmune hepatitis have been reported. Although pathologically indistinguishable from ‘definite' autoimmune hepatitis, they occur with an alloimmune etiology because the liver is of recipient origin while the immune system is of donor origin (therefore, it is autoimmune “like” hepatitis (AILH) precisely). However, the incidence and clinical features of autoimmune-like hepatitis following allogeneic stem cell transplantation (allo-HSCT) are hitherto unknown. Therefore, the aim of this study was to investigate the characteristics of AILH after allo-HSCT mainly in comparison with hepatic GVHD. Methods:A total of 66 patients (median age=38) with malignant (n=62) and benign (n=4) hematological disorders were enrolled in this study, who underwent liver biopsy because of liver complication after allo-HSCT at the Japanese Red Cross Nagoya First Hospital between 1991 and 2010. Fifteen of the 66 patients were autopsied. Because two patients received liver biopsy twice separately, 68 specimens were investigated. The clinical course, liver function tests (T-Bil, AST, ALT, ALP, γGTP, LDH), and response to the treatment were investigated in each case. Clinical characteristics of each pathological diagnosis, especially AILH and GVHD, were studied. AILH was pathologically diagnosed according to the revised International Autoimmune Hepatitis Group diagnostic criteria (interface hepatitis, predominantly lymphoplasmacytic infiltrates and resetting of liver cells), while hepatic GVHD was based on dysmorphic or destroyed small bile dusts with infiltration of CD8+ T cells forming lymphoepithelial lesions. The onset of the hepatic complications was defined as the day when three of the liver function tests changed abnormal. Results:Conditioning regimes were myeloablative (n=52), and reduced intensity (n=14). Donors were HLA-matched (n=51) and mismatched (n=15), related (n=39) and unrelated (n=27). Graft sources were bone marrow (n=54), peripheral blood (n=11), and cord blood (n=1). GVHD prophylaxis consisted of a combination of short-term methotrexase and tacrolimus (n=23) or cyclosporine (n=43). Pathological diagnosis of hepatic complications included AILH (n=5), GVHD (n=23), ischemic colangiopathy (n=11), VOD/SOS (n=6), steatohepatitis (n=4), and others (n=17). Comparing AILH with GVHD, the onset of AILH (median 320, range 133–2631) was significantly later than that of GVHD (median 90, range 29–422) (p=0.005). Consequently, the day of biopsy was also delayed significantly (AIH: median 349, range 187–2647; GVHD: median 133, range 34–586) (p=0.01) in the patients of AILH. Elevation of AST (AILH: median 628, range 508–1215; GVHD: median 289, range 107–1358) was significantly higher in patients with AILH than patients with GVHD (p=0.007). T-Bil (AILH: median 9.8, range 1.2–34.9; GVHD: median 3.3, range 1.2–31.6) and ALT (AILH: median 628, range 517–1586; GVHD: median 573, range 216–2065) were relatively higher in patients with AILH. Immunologically, two of four patients tested were positive for anti-smooth muscle antibody, and one patient out of four tested had a high anti-nuclear antibody titer (1:360) in AILH group. Three of five patients (60%) with AILH and eighteen of 23 patients (78%) with GVHD received steroid therapy and other patients received only supportive care. In patients received steroid therapy, all three patients (100%) improved in AILH group, while only 12 of 18 patients (66%) improved in GVHD group. In addition, all liver function tests were normalized in three patients with AILH (60%), while in only five patients with GVHD (22%). After a median follow-up of 7.4 years, the estimated 5-year OS was 31.4% in this whole cohort. The estimated 5-year OS was 75.0% in patients with AILH and 29.8% in patients with GVHD, respectively. Conclusion: AILH was not a rare hepatic complication following allo-HSCT because five cases (8.5%) in this study were diagnosed with AILH. Compared with GVHD, AILH showed later onset, and higher elevations of transaminases. Treatment with steroids dramatically improved hepatic dysfunction in AILH. Therefore, AILH is a disease entity different from hepatic GVHD, and it should be included in the differential diagnosis of hepatic complication after allo-HSCT. Disclosures:No relevant conflicts of interest to declare.

Glutathione S-Transferase T1 Mismatch and Presence of Anti-GSTT1 Antibodies In Hepatic Gvhd

AbstractAbstract 2323Graft-versus-host disease (GVHD) remains a major complication after allogenic hematopoietic stem-cell transplantation (alloHSCT) from HLA-identical donor. It is due to donor T-cell responses against minor histocompatibility antigens (mHags) of the recipient. Nevertheless, there is a complete lack of studies addressing the B-cell response to mHags in GVHD. Glutathione S-transferase T1 (GSTT1) is a drug metabolizing enzyme that is involved in detoxification processes. It is highly expressed in liver, kidney and erythrocytes. The GSTT1 gene is absent in 20% of the Caucasian population. In liver and renal transplantation, we have reported that some GSTT1-negative patients who received a GSTT1-positive graft produce anti-GSTT1 antibodies (abs) and present signs of chronic rejection. The aims of this study were to analyze the effects of GSTT1 donor/recipient mismatches in the development of hepatic GVHD and to detect production of anti-GSTT1 abs after alloHSCT. For that purpose, we have studied a group of 40 patients that received an alloHSCT from HLA-identical donors between January 2004 and July 2009 in HU Virgen del RociÃŒo, whose DNA samples and their corresponding donor samples were available. All patients and their donors gave written informed consent. GSTT1 genotyping was performed by PCR and a commercially available ELISA test with the GSTT1 human recombinant protein was used to detect anti-GSTT1 abs. We studied abs in serum samples corresponding to different pre and post transplant phases. The distribution of the four possible GSTT1 genetic combinations was as follows: 25 donor+/recipient+, 6 donor+/recipient-, 5 donor-/recipient+ and 4 donor-/recipient-. Anti-GSTT1 antibodies were detected in 5 patients all of them with a donor that carries the null genotype. Four of the 5 patients included in the donor-/recipient+ group developed anti-GSTT1 abs (of the IgG class) after the infusion and were diagnosed with acute hepatic GVHD. In all of these cases the donor was a multiparous female. The presence of anti-GSTT1 abs is significantly associated with hepatic GVHD (p=0,01, Table 1). The fifth recipient within this group had a non-transfused male donor and did not produce abs. In all the cases, anti-GSTT1 abs were found in post-transplant serum samples of the recipient (never in pre-transplant samples) under a condition of 100% chimerism. Our hypothesis is that the immune system of the null donors has encountered the GSTT1 antigen during pregnancy of a positive-fetous and memory B-cells would be in the peripheral blood stem-cell infusion. These cells, once in a positive recipient, would be activated when contacted with the antigen present in the recipientxs liver. In the patients, the B-cells produced high levels of anti-GSTT1 abs that were associated with GVHD episodes. In conclusion, we describe that the presence of anti-GSTT1 abs is associated with the development of hepatic graft-versus-host-disease and that the null genotype of the donor is a necessary condition for antibody-production. These results confirm the GSTT1 gene as new minor histocompatibility antigen.With Hepatic GVHDWithout Hepatic GVHDWith415anti-GSTT1 absWithout anti-GSTT1 abs629351030n = 40 Disclosures:No relevant conflicts of interest to declare.

Etanercept for Steroid-Refractory Acute Graft-Versus-Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation.

AbstractAbstract 4548 Background:Treatment strategy for steroid-refractory acute graft versus host disease (aGvHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is to be standardized. We report our clinical experience of Etanercept, recombinant human soluble tumor necrosis factor receptor fusion protein, on steroid-refractory aGvHD, retrospectively. Method:A total of 18 patients who received allo-HSCT and presented with steroid-refractory aGvHD in Ajou University Hospital were studied retrospectively. Twenty five miligram of Etanercept was given subcutaneously twice weekly for 4 weeks. Clinical responses were checked with regard to the severity of aGvHD. Results:Median age was 43.5 years. Patients with AML, myeloma, ALL, aplastic anemia, myelodysplastic syndrome and idiopathic myelofibrosis were studied. The engraftment kinetics was adequate and no one failed to engraft. Before Etanercept, grade 4, grade 3, grade 2 and grade 1 of aGvHD occurred in 7, 6, 5, and zero patients, respectively however the number of patients were changed to 4, 5, 5, and 4 after Etanercept, respectively (p = .005). Eighty percent of grade II and 57% of grade IV patients showed partial response, so did in 14% of grade III patients. Skin and gut aGvHD was well controlled with Etanercept, whereas hepatic GvHD was not. Three patients died of severe infection. There was no factor affecting clinical outcome of Etanercept. All the non-responders died but 56.6% of the responders survived (p = 0.003). Conclusion:Etanercept can be one of the effective anti-aGvHD drugs for steroid-refractory cases after allo-HSCT considering tolerable side effects and tolerable cost. Disclosures:No relevant conflicts of interest to declare.