Late aGVHD Research Articles

Vedolizumab for second-line treatment of steroid-refractory gastrointestinal late acute graft-versus-host disease.

Late acute graft-versus-host disease (aGVHD) is a complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT) with little data regarding treatment and outcomes. There is no standard treatment for gastrointestinal (GI) late aGVHD, especially for steroid-refractory (SR) GI late aGVHD. Vedolizumab, a monoclonal antibody inhibiting the migration of both naive and activated lymphocytes into the GI endothelium, has been verified to be effective for SR GI aGVHD. We retrospectively analyzed the clinical efficacy and safety of vedolizumab as the second line for SR GI late aGVHD in seven patients after allo-HSCT. Four patients received two doses of vedolizumab infusion, while three patients received only one dose of vedolizumab infusion. The complete response and partial response rates were 57.1% (4/7) and 42.9% (3/7), respectively. No patient progressed to chronic GVHD during the period of follow-up. There was no severe adverse event related to vedolizumab. Our data suggest that vedolizumab is expected to ameliorate SR GI late aGVHD. Further data on the treatment timing, efficacy, and safety of vedolizumab are warranted in prospective clinical trials.

Preconditioning Single High-Dose Palifermin Alters the Posttransplant Inflammatory Cytokine Profile

Palifermin is a truncated form of human recombinant keratinocyte growth factor (KGF) that binds to the FGF receptor 2b expressed in epithelia including that of the epidermis, oral and GI mucosa, and thymus. In animal models, the cytoprotective and regenerative effects of KGF showed efficacy in controlling acute and chronic graft-versus-host disease (A/C GVHD), but these were not demonstrated in subsequent clinical studies using the FDA-approved dosing schedule for oral mucositis prevention (60 µg/kg/day for 3 consecutive days). The current study aims to investigate alterations in immune cell reconstitution and cytokine expression among patients (n=31) participating in the ongoing prospective open-label phase 1/2 trial NCT02356159. This trial evaluates the incidence of severe CGVHD (primary objective of phase 2) following the addition of a single high dose of palifermin to GVHD prophylaxis with TMS (tacrolimus, methotrexate, sirolimus). Four different dose levels of palifermin (DL1: 180 µg/kg; DL2: 360 µg/kg; DL3: 540 µg/kg; DL4: 720 µg/kg) were tested on day −7 in the phase 1 part of the trial, with the recommended phase 2 dose being 720 µg/kg. All patients received cyclophosphamide (total 4.8 g/m 2) and fludarabine (total 120 mg/m 2) as conditioning on days −6 to −3 followed by infusion of an 8/8 HLA-matched unrelated donor peripheral blood cell graft on day 0. Results of correlative studies were compared with patients of the identical TMS treatment arm of the NCT00520130 study without palifermin (n=31). In the DL4 group, a previous interim analysis revealed no cases of classic (day +100) AGVHD II-IV in 16 patients (P=0.014), whereas the TMS group showed a 22.6% (95% CI: 9.8% to 38.6%) incidence (Schulz et al. Cell Ther Transplant. 2023;29(2):S258). T, B and NK cells were routinely measured by flow cytometry at days +14, +28, +60, +100, +180, +365, +730. The V-PLEX human cytokine 36-plex kit and U-PLEX assays of human BAFF, CXCL9 and IL1RL1/ST2 (all MSD, Rockville, MD) were used to measure cytokine levels in plasma at days −8, 0, +14, +28, +60, +100. The measures at various time points were compared between two treatment groups using multiple Mann-Whitney tests, and the false discovery rate approach was applied with Q=0.05. Comparison between the four DL groups and the TMS group was performed using the Kruskal-Wallis H-test and Dunn's post-hoc test, with a significance threshold set at P<0.05. The statistical analyses were conducted using GraphPad Prism 9. In comparison to patients receiving TMS only, those treated with KGF exhibited reduced NK cell counts at day +28 (Q=0.0155) and increased B cell counts from day +60 (Q<0.01) onwards. However, there were no differences in the absolute numbers of CD3+, CD4+, and CD8+ T cells between patients from both trials. Additionally, no apparent dose-response relationship was observed. KGF-treated patients showed significantly reduced plasma levels of proinflammatory cytokines, including TNF-α at day 0, TNF-β at days 0, +14, +28, IL-12/IL23p40 at days 0 and +14, and CXCL9 at days 0 and +14, compared to patients receiving TMS only. Notably, levels of homeostatic IL-7, previously linked to AGVHD, were significantly lower in KGF-treated patients from day +28 (TMS vs. DL4, P=0.002) to +100. There was a trend towards lower levels of IL-22 at days 0 and +14 (both unadjusted P<0.05, Q>0.05) in KGF-treated patients. Other proinflammatory biomarkers showed increased levels in KGF-treated patients: IL-15 at day 0 (Q=0.0121), BAFF at days +14 and +28 (both Q<0.01), and ST2 at day 0 and day +14 (both Q<0.01). As reported previously by others, patients who developed classic or late onset AGVHD II-IV without prior relapse up to day +180 had higher ST2 levels at day +14 compared to patients without AGVHD II-IV (P=0.03). Here, this association was mainly observed in patients from the TMS and DL1 groups (6/8 tested patients with any AGVHD II-IV). The administration of a single high dose of palifermin (KGF) prior to conditioning treatment resulted in a notably distinct cytokine profile, characterized by a reduction in several GVHD associated pro-inflammatory cytokines, consistent with KGF's proposed cytoprotective effect. Further investigations focusing on GI microbiome and immune cell subsets are needed to elucidate the consequences of cytokine alterations induced by KGF on immune cell reconstitution. This research was supported by the Intramural Research Program of the NIH, NCI, CCR.

Circulating cell-free mitochondrial DNA as a diagnostic and prognostic biomarker in chronic and late acute graft-versus-host disease in children

In an earlier study, we found that mitochondrialDNA(mtDNA) concentration is elevated in adults with chronic graft-versus-host disease (cGvHD), acting as an endogenous source of TLR9 agonists to augment B-cell responses. To validate this in children, we evaluated mtDNA plasma expression in a large pediatric cohort (ABLE/PBMTC 1202 study). Plasma cell-free mtDNA (cf-mtDNA) copy numbers were measured in 202 pediatric patients using quantitative Droplet Digital polymerase chain reaction (ddPCR). Two evaluations were performed: 1) before the onset of cGvHD or late acute graft-versus-host disease (aGvHD) at day 100 ± 14 days and 2) at the time of cGvHD onset compared with time-matched non-cGvHD controls. We found that cf-mtDNA copy numbers were not affected by immune reconstitution post-hematopoietic stem cell transplantation but were higher on day 100 before the onset of late aGvHD and at the onset of cGvHD. We found that cf-mtDNA was not impacted by previous aGvHD, but correlated with the early onset, NIH moderate/severe cGvHD, and did not correlate with other immune cell populations, cytokines, or chemokines but did with the metabolites spermine and taurine. Similar to adults, children have elevated plasma cf-mtDNA concentrations at the early onset of cGvHD, especially in NIH moderate/severe cGvHD, elevation with late aGvHD, and associated with metabolites involved in mitochondrial function.

Increased risk of nonrelapse mortality post T-cell-replete haploidentical stem cell transplantation in patients with recurrence of acute graft-versus-host disease.

Acute graft-versus-host disease (aGVHD) causes significant morbidity and mortality. While most studies focus on classic or late aGVHD, some patients with previous aGVHD achieve complete remission and later develop another episode of aGVHD. Data on recurrence of aGVHD (RaGVHD) are lacking. This study aimed to identify the incidence, risk factors, and impacts of RaGVHD after T-cell-replete haploidentical hematopoietic cell transplantation (haplo-HCT) without posttransplantation cyclophosphamide. We evaluated patients with RaGVHD after haplo-HCT between 2017 and 2019 and compared their outcomes to those of patients with no aGVHD and those of patients with one episode of de novo aGVHD. Of 199 patients included in the analysis, 45 experienced 50 cases of RaGVHD with a 1-year cumulative incidence of 19.0% (95% CI: 14.5-24.6). Grade III-IV aGVHD was more common in RaGVHD than in previous aGVHD (22.2% vs. 4.4%, p=0.01). Female donor to male recipient was strongly associated with RaGVHD (HR: 2.5, p=0.009). The most common death in patients with RaGVHD was GVHD-related, which was different from controls who mostly died from relapse (p=0.008). RaGVHD was an independent risk factor for chronic GVHD (HR: 2.6, p=0.006) and nonrelapse mortality (HR: 2.4, p=0.019) and a significant predictor of lower GVHD relapse-free survival (HR: 1.9, p=0.020) and cGVHD relapse-free survival (HR: 2.1, p=0.007). In conclusion, clinical manifestations and negative impacts of RaGVHD needs to be recognized independently.

Efficacy of basiliximab in the treatment of 87 cases of steroid-refractory or steroid-dependent acute graft-versus-host disease

目的分析巴利昔单抗治疗异基因造血干细胞移植后糖皮质激素耐药/依赖急性移植物抗宿主病（aGVHD）患者的疗效。方法对2015年1月至2018年12月期间于中国医学科学院血液病医院行异基因造血干细胞移植后发生皮肤、肠道、肝脏aGVHD并应用巴利昔单抗治疗的87例血液病患者进行回顾性分析。巴利昔单抗用药方案：成人及体重≥35 kg儿童每次20 mg，体重<35 kg儿童每次10 mg，第1、4、8天各给药1次，以后每周用药1次，在巴利昔单抗治疗后第7、14、21、28、42、56天分别进行疗效评估。结果①87例患者中，男51例（58.6％），女36例（41.4％），中位年龄34（4～63）岁，经典型aGVHD 54例，迟发型aGVHD 33例，糖皮质激素耐药49例，糖皮质激素依赖38例。②35例（40.2％）获得完全缓解（CR），23例（26.4％）获得部分缓解（PR），29例患者未缓解（NR），总有效率（ORR）为66.7％（58/87）。③经典型aGVHD组、迟发型aGVHD组ORR分别为77.8％（42/54）、48.5％（16/33）。④中位随访154（4～1813）d，全部87例患者移植后6个月总生存（OS）率为44.8％（95％CI 39.5％～50.1％），移植后1年OS率为39.4％（95％CI 34.2％～44.3％）。⑤巴利昔单抗治疗后CR组（35例）、PR组（23例）、NR组（29例）移植后6个月OS率分别为80.0％（95％CI 73.2％～86.8％）、39.1％（95％CI 28.9％～49.3％）、6.9％（95％CI 2.2％～11.6％）（χ2＝34.679，P<0.001），移植后1年OS率分别为74.3％（95％CI 66.9％～81.7％）、30.4％（95％CI 20.8％～40.0％）、3.4％（95％CI 0％～6.8％）（χ2＝43.339，P<0.001）。经典型aGVHD组、迟发型aGVHD组移植后6个月OS率分别为57.4％（95％CI 50.7％～64.1％）、24.2％（95％CI 16.7％～31.7％）（χ2＝9.109，P＝0.004），移植后1年OS率分别为51.9％（95％CI 45.1％～58.7％）、18.2％（95％CI 11.5％～24.9％）（χ2＝9.753，P＝0.003）。⑥单因素及多因素分析结果显示，迟发型aGVHD（OR＝3.121，95％CI 1.770～5.503，P<0.001）、用药前明尼苏达积分高危组（OR＝3.591，95％CI 1.931～6.679，P<0.001）、用药前存在活动性感染（OR＝1.881，95％CI 1.029～3.438，P＝0.040）、伴有非GVHD所致重要脏器功能受损（OR＝3.100，95％CI 1.570～6.121，P＝0.001）是影响巴利昔单抗疗效的独立危险因素。结论巴利昔单抗对于糖皮质激素耐药/依赖aGVHD具有良好的疗效和安全性；迟发型、用药前明尼苏达积分高危组、存在感染或重要脏器功能受损患者疗效不佳。

Metabolomic identification of α-ketoglutaric acid elevation in pediatric chronic graft-versus-host disease

AbstractChronic graft-versus-host disease (cGVHD) is the most common cause for non-relapse mortality postallogeneic hematopoietic stem cell transplant (HSCT). However, there are no well-defined biomarkers for cGVHD or late acute GVHD (aGVHD). This study is a longitudinal evaluation of metabolomic patterns of cGVHD and late aGVHD in pediatric HSCT recipients. A quantitative analysis of plasma metabolites was performed on 222 evaluable pediatric subjects from the ABLE/PBMTC1202 study. We performed a risk-assignment analysis at day + 100 (D100) on subjects who later developed either cGVHD or late aGVHD after day 114 to non-cGVHD controls. A second analysis at diagnosis used fixed and mixed multiple regression to compare cGVHD at onset to time-matched non-cGVHD controls. A metabolomic biomarker was considered biologically relevant only if it met all 3 selection criteria: (1) P ≤ .05; (2) effect ratio of ≥1.3 or ≤0.75; and (3) receiver operator characteristic AUC ≥0.60. We found a consistent elevation in plasma α-ketoglutaric acid before (D100) and at the onset of cGVHD, not impacted by cGVHD severity, pubertal status, or previous aGVHD. In addition, late aGVHD had a unique metabolomic pattern at D100 compared with cGVHD. Additional metabolomic correlation patterns were seen with the clinical presentation of pulmonary, de novo, and progressive cGVHD. α-ketoglutaric acid emerged as the single most significant metabolite associated with cGVHD, both in the D100 risk-assignment and later diagnostic onset analysis. These distinctive metabolic patterns may lead to improved subclassification of cGVHD. Future validation of these exploratory results is needed. This trial was registered at www.clinicaltrials.gov as #NCT02067832.

Real-Time Reflectance Confocal Microscopy of Cutaneous Graft-versus-Host Disease Correlates with Histopathology

Reflectance confocal microscopy (RCM) allows noninvasive, real-time evaluation of the skin at a resolution akin to histopathology (HP), but its application in cutaneous graft-versus-host disease (GVHD) has not been extensively assessed. We describe RCM features of cutaneous GVHD including acute (aGVHD), late acute, chronic (cGVHD; sclerotic and nonsclerotic subtypes), and inactive GVHD and correlate RCM with same-site HP for a subset of patients. Thirty-two adult and pediatric allogeneic hematopoietic cell transplantation (allo-HCT) recipients with cutaneous GVHD received RCM imaging of ≥1 lesions (n = 44), 13 of which necessitated skin biopsy. RCM images were deidentified and assessed by 2 RCM experts blinded to clinical and HP findings to reach a consensus on the features and patterns of the inflammatory dermatoses. Major RCM features (present in ≥65% of lesional sites) and patterns were reported. To determine the correlation between RCM and HP, detection of cellular features and patterns of inflammatory dermatoses were compared using percent agreement and prevalence-adjusted, bias-adjusted kappa estimates. Seven patients with early or late aGVHD (7 lesions) had irregular honeycombing, spongiosis, dermoepidermal junction (DEJ) and dermal inflammation, and melanophages; those with early aGVHD also had hyperkeratosis, dilated vessels, and coarse connective tissue. Both groups had an interface dermatitis pattern. Eighteen patients with nonsclerotic cGVHD (24 lesions) had irregular honeycombing, spongiosis, DEJ and dermal inflammation, dilated vessels, coarse connective tissue, and interface and spongiotic dermatitis patterns. Three sclerotic patients with cGVHD (7 lesions) had irregular honeycombing, DEJ and dermal inflammation with an interface dermatitis pattern. Four patients with inactive GVHD (6 lesions) showed minimal inflammation. RCM and HP had similar detection rates for 6 of 13 features and overall patterns important for diagnosis in 2 patients with late aGVHD (2 lesions; 15%) and 10 with nonsclerotic cGVHD (11 lesions; 85%) necessitating skin biopsy. RCM can detect features commonly reported in cutaneous GVHD and is comparable to HP. Additional characterization of cutaneous GVHD by RCM may enable future use in diagnosing, monitoring, or predicting disease in real time.

Late-Onset Acute and Chronic Graft-versus-Host Disease in Children: Clinical Features and Response to Therapy

Although acute graft-versus-host disease (aGVHD) and chronic GVHD (cGVHD) are known causes of morbidity and mortality after allogeneic hematopoietic cell transplantation (HCT), the syndrome of late aGVHD is less well understood, particularly in children. We aimed to characterize the clinical features and response to therapy of late aGVHD and cGVHD by retrospectively reviewing 573 consecutive patients age <18 years who underwent their first allogeneic HCT at the University of Minnesota. We included patients with de novo late aGVHD (ie, first occurrence of aGVHD after day +100 post-HCT) and cGVHD. We retrospectively scored cGVHD cases based on the 2014 National Institutes of Health guidelines. At 3 years, 9 patients (2%) had developed late aGVHD, 16 (3%) had overlap cGVHD, and 7 had (1%) classic cGVHD. No cases of joint or genital cGVHD were observed. The overall response to therapy at 6 months was 78% (95% confidence interval [CI], 40% to 97%) after late aGVHD and 43% (95% CI, 23% to 66%) after cGVHD. Higher nonrelapse mortality from day +100 was seen in patients with cGVHD but not in those with late aGVHD compared with patients without GVHD (hazard ratio, 3.6 [95% CI, 1.3 to 10.0] and 1.6 [95% CI, 0.2 to 11.7], respectively). We found variable organ involvement and treatment responses between patients with late aGVHD and those with cGVHD in a single-center pediatric cohort. Further research is needed to investigate the risks and clinical features of late aGVHD and cGVHD in larger cohorts to better understand how to tailor even more effective GVHD preventive and therapeutic approaches in children.

Sustained Donor Chimerism and Rapid Immune Cell Reconstitution with a Low Probability of Gvhd Following Familial Haploidentical (FHI) CD34 Enriched Stem Cell Transplantation with Pbmnc Addback in Patients with High Risk Sickle Cell Disease (SCD) (IND 14359)

Background Allogeneic stem cell transplantation (AlloSCT) from an HLA-matched sibling donor is the only known curative therapy in high-risk SCD patients (Talano/Cairo, EJH, 2015). Unfortunately only about 15% of high-risk SCD patients have an HLA-matched unaffected sibling donor. T cell depletion has been employed to reduce AGVHD. We reported a very low incidence of GVHD in pediatric recipients receiving CD34 enriched HPC products with PBMNC addback from MUD donors (Geyer/Cairo et al, BJH, 2012). Rapid NK cell reconstitution after AlloSCT is associated with a significant improvement in 1yr OS (Pical-Izard, BBMT, 2015). Recently, we reported promising results for high-risk SCD patients at 1 yr follow-up after FHI CD34 enriched/PBMNC with addback with the probability of 1-yr OS 88.2% (Cairo, et al, JAMA Peds, 2019). Objective To investigate donor chimerism, immune reconstitution and the incidence of GVHD in high-risk SCD patients following AlloSCT using FHI CD34 enrichment/PBMNC (2 × 105 CD3/kg) addback. Methods CD34 cells were enriched using the CliniMACS® system, kindly provided by Miltenyi Biotec, with a target dose of 10 × 106 CD34+ cells/kg. PBMNC were added back to the final CD34 product at a dose of 2 × 10*5 CD3/kg. Whole blood and CD71-enriched erythroid lineage chimerism were determined by STR. Immune cell, subset reconstitution, NK function, CD107a and granzyme B were assessed by flow cytometry as previously described (Geyer/Cairo et al. BJH, 2012, Chu/Cairo et al, Can Imm Res, 2015). Results The cumulative incidence of grade II-IV and late AGVHD was 6.2 % and moderate and/or severe CGVHD incidence was 6.7%, respectively (Fig. 1A). There was 100% engraftment of neutrophils and platelets. The median day post-HISCT to neutrophil and platelet engraftment was +9 and +19, respectively. Whole blood donor chimerism (mean±SEM) at 1-yr, 2-ys, and 3-ys post-HISCT was 97±1%, 97±1%, 97±1%, respectively (Fig.1B). Donor chimerism for CD71-enriched erythroid lineage cells (mean±SEM) at 1-yr, 2-yrs, 3-yrs post-HISCT was 97±2%, 98±1%, 98±1%, respectively (Fig.1B). The time to recovery of minimal normal levels for CD3 (800 cells/ul), CD4 (400 cells/ul), CD8 (200 cells/ul), & CD19 cells (200 cells/ul), was approximately 365, 365, 270, and 60 days post-HISCT, respectively (Fig.1C). NK reconstitution was rapid and peaked at d+30 (36±9%) with higher level of activating receptors NKp46, NKG2D & KIR2DS and inhibitory receptors NKG2A, CD94 and KIR2DL2/3. NK cytotoxicity against K562 (E:T = 10:1) peaked at d+30 and d+180 vs pre-transplant (p Conclusion The PBMNC addback facilitated rapid donor chimerism & immune reconstitution with a low probability of Grade II-IV AGVHD. The rapid NK reconstitution may have in part contributed to the excellent 1yr OS in this study (FDA R01FD004090 (MSC)). This approach is comparable to the method of CD3 TCRa/b-CD19 depletion.

Demodex Folliculorum Infestation Mimicking Acute Cutaneous GVHD

<h3>Introduction</h3> Demodex folliculorum (DF) mites are inhabitants of the human pilosebaceous unit and are part of normal skin flora. They have a predilection for the face due to high sebum concentration in this area. While rarely symptomatic in the immunocompetent, (DF) mites are found in greater density and are more pathogenic in the immunocompromised. Symptomatic DF infestations in the immunocompromised have been described in the past; however, there is scarce literature regarding this condition in hematopoietic stem cell transplant (tx) recipients, where its clinical presentation is like acute graft versus host disease (aGvHD) of the skin. <b>Case:</b> A 73-year-old male diagnosed with AML underwent reduced-intensity peripheral blood matched unrelated donor tx. GvHD prophylaxis was with post-tx cyclophosphamide and cyclosporine. Post-tx day 32, he presented with sudden onset facial puffiness, redness and bilateral periorbital edema (figure 1). On physical exam, he had bilateral periorbital edema with thickened red skin over the forehead, cheeks, mandible, and submandibular areas. He had a skin biopsy and due to concerns of aGVHD, he was treated with topical hydrocortisone, oral antihistamines, and systemic corticosteroids. While his symptoms improved, the rash did not resolve. Biopsy showed mixed perifollicular inflammation with DF mites (figure 2). Based on these findings he was treated with 2 doses of Ivermectin 200 mcg/kg and the rash completely resolved. <h3>Discussion</h3> There have been a few reports of DF infestation in tx patients, most presented within 100 days of tx mimicking aGvHD. However, a few have, reported onset of rash after the withdrawal of immunosuppression, presenting like cutaneous late aGvHD. In all these cases, the patient presented with a characteristic facial rash with a sharp demarcation between the scalp and forehead known as the "cut off" sign. The tendency to spare the scalp may be due to the differences in the pilosebaceous units of the scalp compared with those on the face, this may help distinguish it from cutaneous aGvHD. Treatment with mite directed therapy can rapidly treat this condition.

Pilot study using post-transplant cyclophosphamide (PTCy), tacrolimus and mycophenolate GVHD prophylaxis for older patients receiving 10/10 HLA-matched unrelated donor hematopoietic stem cell transplantation.

Allogeneic SCT for older patients remains challenging at least in part due to graft-versus-host disease (GVHD) and higher non-relapse mortality (NRM). We conducted a prospective pilot study primarily for older patients undergoing matched unrelated donor (MUD) SCT using a reduced-intensity (RIC) melphalan-based conditioning and post-transplant cyclophosphamide (PTCy)-based GVHD prophylaxis with tacrolimus and mycophenolate mofetil. Twenty-two patients (median age 64, IQR 58, 66) underwent RIC MUD SCT for high-risk hematological malignancies including AML/MDS (73%), CML/MPD (18%), and other (10%). Two (9%) patients had early death; the rest (100%) engrafted. After a median follow-up of 17 months, 11 patients were alive and disease-free with an estimated 2-year progression-free (PFS) and overall (OS) survival of 48%. The cumulative incidences of grades 2-4 and 3-4 acute GVHD (aGVHD) at day + 100 and 2-years were 32 and 4%, and 59 and 24%, respectively. No cases of chronic GVHD (cGVHD) were noted. However, late acute GVHD was observed in 6 (27%) patients. In conclusion, RIC MUD SCT with melphalan-based conditioning and PTCy-based GVHD-based prophylaxis for older patients appears effective in controlling relapse. While cGVHD was not seen and early aGVHD appears controllable, a significant proportion developed late aGVHD responsible for higher NRM seen in these patients.

Impact of Human Leukocyte Antigen Loci and Haplotypes on Intestinal Acute Graft-versus-host Disease after Human Leukocyte Antigen-matched Sibling Peripheral Blood Stem Cell Transplantation.

Background:Acute graft-versus-host disease (aGVHD) is a common and severe complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). Some studies have found that the presence of certain specific human leukocyte antigen (HLA) loci could affect the occurrence of aGVHD. Meanwhile, the impact of HLA haplotypes on aGVHD has been rarely studied. This study aimed to investigate the effects of HLA loci and haplotypes on intestinal aGVHD.Methods:Totally, 345 consecutive patients undergoing first HLA-matched sibling peripheral blood stem cell transplantation (PBSCT) from February 2004 to June 2013 at Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, were enrolled in this study. HLA loci and haplotypes of recipients with frequency over 5% were searched and their effects on intestinal aGVHD were investigated. Other important factors including donor age, recipient age, donor-recipient sex combinations, and conditioning regimens were also evaluated using logistic regression. Pure upper gastrointestinal tract aGVHD without diarrhea was excluded because the histological proof was unavailable. The follow-up end-point was 6 months after HSCT.Results:The cumulative incidence of intestinal aGVHD was 19.4%, with 18.0% of the patients classified as classic aGVHD and 1.4% as persistent, recurrent, or late aGVHD. Multivariate analysis showed that HLA-A31 locus (odds ratio [OR] 2.893, 95% confidence interval [CI] [1.054, 7.935], P = 0.039), HLA B40-DR15 (OR 3.133, 95% CI [1.250, 7.857], P = 0.015), and HLA B46-DR9 haplotypes (OR 2.580, 95% CI [1.070, 6.220], P = 0.035), female donor for male recipient (OR 2.434, 95% CI [1.319, 4.493], P = 0.004) were risk factors for intestinal aGVHD.Conclusion:The presence of certain HLA loci and haplotypes may influence the occurrence of intestinal aGVHD in PBSCT with HLA-identical sibling donors.

Late Acute Graft-versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation

There are little data regarding the incidence, clinical manifestations, risk factors, and outcomes of late acute graft-versus-host disease (aGVHD). We evaluated patients with late aGVHD after allogeneic hematopoietic cell transplantation (HCT) between 2007 and 2012 and compared their outcomes to patients with early-onset aGVHD. Of the 511 allogeneic HCT recipients, 75 developed late aGVHD (cumulative incidence: 14.7% (95% confidence interval [CI], 11.6% to 17.8%) versus 248 with early-onset aGVHD (cumulative incidence: 49% [95% CI, 45% to 53%]). Among those with late aGVHD, 52% had persistent, 39% had recurrent, and 9% had de novo late aGVHD. Advanced (grades III and IV) early-onset aGVHD was associated with a higher risk of developing late aGVHD (hazard ratio [HR], 1.9; 95% CI, 1.2 to 3.1; P = .01). Forty-eight percent (95% CI, 36% to 60%) of late aGVHD versus only 31% (95% CI, 26% to 37%) of early-onset aGVHD progressed to chronic GVHD by 2 years. Higher proportion of persistent (53%) as compared to recurrent (39%) and de novo (46%) late aGVHD progressed to cGVHD at 2 years. The overall survival was 59% (95% CI, 49% to 72%) in late aGVHD and 50% (95% CI, 44% to 57%) in early-onset aGVHD. Persistent late aGVHD had worse overall survival and nonrelapse mortality (45% and 39%, respectively) than recurrent (74% and 18%, respectively) and de novo (83% and 0%, respectively) late aGVHD. Compared with HLA-identical sibling HCT, unrelated donor transplantations were associated with a higher risk of mortality in patients developing late aGVHD (HR, 6.1; 95% CI, 2.3 to 16.2; P < .01). In a landmark analysis (evaluating 100-day survivors among early-onset aGVHD), no difference was seen in late mortality (after 100 days) between early-onset and late aGVHD (HR, .96; 95% CI, .59 to 1.55; P = .85); however, the risk of cGVHD was nearly doubled (HR, 1.81; 95% CI, 1.16 to 2.82; P = .01) in patients with late aGVHD. Late aGVHD is a relatively common complication after allogeneic HCT. Poorer outcomes in those with persistent late aGVHD imply need for more effective therapy in this group to improve transplantation outcomes. A higher risk of subsequent chronic GVHD needs further evaluation and close monitoring.

Late Acute and Chronic Graft-versus-Host Disease after Allogeneic Hematopoietic Cell Transplantation

Several distinct graft-versus-host disease (GVHD)-related syndromes have been defined by the National Institutes of Health Consensus Conference. We enrolled a prospective cohort of 911 hematopoietic cell transplantation (HCT) recipients at 13 centers between March 2011 and May 2014 to evaluate 4 GVHD syndromes: late acute GVHD (aGVHD), chronic GVHD (cGVHD), bronchiolitis obliterans syndrome, and cutaneous sclerosis. The median age at HCT was 53.7 years. The majority of patients received a peripheral blood stem cell transplant (81%) following nonmyeloablative or reduced-intensity conditioning (55%). Pediatric age group and use of bone marrow and umbilical cord blood grafts were underrepresented in our cohort (≤11%). The cumulative incidence of late aGVHD (late onset and recurrent) was 10% at a median of 5.5 months post-HCT, that of cGVHD was 47% at a median of 7.4 months, that of bronchiolitis obliterans was 3% at a median of 12.2 months, and that of cutaneous sclerosis was 8% at a median onset of 14.0 months. Late aGVHD and bronchiolitis obliterans had particularly high nonrelapse mortality of 23% and 32%, respectively, by 2 years after diagnosis. The probability of late aGVHD- and cGVHD-free, relapse-free survival was 38% at 1 year post-HCT and 26% at 2 years post-HCT. This multicenter prospective study confirms the high rate of late aGVHD and cGVHD syndromes and supports the need for continuous close monitoring and development of more effective GVHD treatment strategies to improve HCT success.

Late Onset Acute GVHD (late aGVHD) after Allogeneic Hematopoietic Stem Cell Transplantation (HCT)

Late Onset Acute GVHD (late aGVHD) after Allogeneic Hematopoietic Stem Cell Transplantation (HCT)

NIH-defined graft-versus-host disease and evidence for a potent graft-versus-leukemia effect in patients with acute lymphoblastic leukemia

BackgroundThe prognostic value of the NIH consensus criteria for graft-versus-host disease (GVHD) is not well defined yet. Patients and methodsWe analyzed NIH-defined GVHD in 147 acute lymphoblastic leukemia (ALL) patients. ResultsThe cumulative incidence of classic acute GVHD (aGVHD), late aGVHD and chronic GVHD (cGVHD) was 63%, 12% and 41%, respectively. cGVHD was subclassified as classic versus overlap syndrome in 40% versus 60% of cases. In multivariate Cox regression analysis with GVHD as time-dependent covariate, classic aGVHD grade III/IV had a negative impact on overall survival (OS) due to higher non-relapse mortality. cGVHD of any grade was associated with superior OS, which was due to lower relapse incidence. Classic cGVHD versus overlap syndrome had no differential impact. In 44 patients without GVHD after transplant who received donor lymphocyte infusions (DLI), the cumulative incidence of classic aGVHD, late aGVHD or cGVHD was 60%, 5% and 57%. Occurrence of cGVHD after DLI was associated with improved OS due to lower relapse incidence. ConclusionsThe NIH consensus criteria for GVHD clearly define prognostic subgroups in patients transplanted for ALL. The improved OS in patients developing cGVHD after transplant or DLI gives clear evidence for a potent graft-versus-leukemia effect in this indication.

A First-in-Disease Trial of in Vivo Costimulation Blockade for Acute GvHD Prevention: The Addition of Abatacept to Standard GvHD Prophylaxis Controls Early CD4+ T Cell Proliferation and Is Associated with Low Rates of Severe Acute GvHD

AbstractAbstract ▪741▪This icon denotes a clinically relevant abstractWe have previously shown that a costimulation blockade-containing regimen could provide effective protection against acute GvHD (aGvHD) in a non-human primate model. We therefore designed a first-in-disease trial of in vivo CD28:CD80/86-directed costimulation blockade with CTLA4-Ig (abatacept) to prevent aGvHD after unrelated-donor HSCT for patients > 12y. (Clinical Trials.Org #NCT01012492). In this trial, 10mg/kg abatacept was administered IV on day −1, +5, +14, +28 in addition to standard prophylaxis with cyclosporine + MTX. Enrollment of all patients is complete, and the study is evaluable for feasibility, toxicity, engraftment, and the primary immunologic outcome: the incidence of Grade III-IV aGvHD by d+100. Patient Characteristics and Survival:10 patients, with a median age of 44.5 y (17–74) were enrolled and treated. 6 patients received HLA-mismatched grafts (matched at 7/8 alleles) and 4 received 8/8 HLA-matched URD grafts. 8 received PBSCs and 2 received BM. All received high-intensity conditioning (Bu/Cy, TBI/Cy or Flu/Mel). With a median follow-up of 367 days (262–680), 7 patients are alive and in remission. 2 patients died of relapse (Day +121 and Day +147). One patient died, in remission, of multi-organ failure on day +453 post-transplant. Feasibility, Pharmacokinetics and Pharmacodynamics of Abatacept in HSCT:All 10 patients received all 4 scheduled abatacept doses, without infusion reactions. The average peak (230.9 +/− 7.4 mg/ml) and trough (45.9 +/− 2.8 mg/ml) abatacept levels, as well as the terminal T1/2 (19.6 +/− 1.9 days) were similar to that observed previously. Importantly, as has been previously established in vitro, patients receiving abatacept demonstrated significant inhibition of post-transplant CD4+ T cell proliferation (with >80% reduction in the accumulation of Ki-67+ proliferating CD4+ T cells at d+14 and +28 compared to a control cohort who received cyclosporine + methotrexate without abatacept, Figure 1). This data establishes, for the first time, the feasibility of giving abatacept to this new patient population, and that the PK and PD parameters in HSCT closely mirror those previously shown to effectively control immune-mediated diseases. Engraftment:All patients achieved neutrophil engraftment (median d+16.5) and donor engraftment (100% CD33 chimerism at d+30). Lymphocyte recovery was rapid: Day +100 mean peripheral blood counts showed ALC = 1053 +/− 259 cells/ml, total T cells = 741 +/− 208 cells/ml, and CD8+ T cells = 381 +/− 99 cells/ml. The Day +100 CD4+ T cells = 285 +/− 105 cells/ml, not significantly different from historical controls (n = 43) that received CNI/MTX aGvHD prophylaxis without abatacept (262 +/−26 cells/ml). GvHD:Patients receiving the abatacept-containing regimen had encouragingly low rates of early severe aGvHD: Two patients developed aGvHD before day +100, with one of these patients (Gr II) progressing to steroid-dependent cGvHD of the liver and one patient (Gr III) with complete resolution of aGvHD (and currently off steroids). The cumulative incidence of grade II-IV and III-IV aGvHD by day 100 was thus 20% and 10%, respectively (Figure 2). Importantly, there was no Gr IV aGvHD, no patient received salvage therapy for aGvHD, and there were no deaths from aGvHD. After day +100, one patient developed late acute GvHD (currently off all immunosuppression), and two patients developed overlap syndrome. Both had responsive disease and are currently either weaning or off corticosteroids. No other patient developed late aGvHD, and no other patient has developed moderate or severe cGvHD. Infection:No life-threatening infections occurred. 5 patients developed CMV reactivation, all responsive to antivirals. No patient developed CMV disease. No EBV viremia >1000 copies/ml occurred. One patient developed EBV+ plasmacytic hyperplasia of the tongue, which resolved without intervention. No other EBV-related disease occurred. Conclusions:This trial demonstrates, for the first time, the feasibility of adding in vivo T cell costimulation blockade with abatacept for aGvHD prevention. The decreased CD4+ T cell proliferation post-transplant and the encouragingly low rates of early, severe aGvHD suggest that costimulation blockade may be an effective agent for aGvHD prophylaxis and support the conduct of a larger, randomized phase 2 study. [Display omitted] [Display omitted] Disclosures:Off Label Use: Abatacept was used in this trial. It is a costimulation blockade agent which was tested for its ability to prevent aGvHD.

Impact of prior acute GVHD on chronic GVHD outcomes: a chronic graft versus host disease consortium study

Chronic graft-versus-host disease (CGVHD) is one of the most debilitating complications post hematopoietic cell transplant (HCT). Several studies have evaluated factors affecting survival in CGVHD,1–8 most utilizing the older definition of CGVHD where patients with any symptoms of GVHD (acute or chronic) may be classified as CGVHD if symptomatic beyond day 100 post HCT. However, the new NIH consensus guidelines have re-defined criteria for CGVHD diagnosis and staging9 based on actual symptoms at presentation and excludes patients with persistent, recurrent or late AGVHD who were previously considered to have CGVHD. The CGVHD consortium follows a large multi-center prospectively enrolled cohort of CGVHD patients utilizing NIH consensus guidelines for assessments.10 Several reports from this consortium have identified factors affecting survival including global severity, thrombocytopenia, KPS and the overlap syndrome.11,12 Prior AGVHD has been associated with a higher mortality in patients who develop CGVHD,1,3 indicating that these patients may be more debilitated and hence suffer worse outcome. However, the clinical and prognostic importance of prior AGVHD on subsequent CGVHD in the current era using NIH diagnostic and staging criteria is unknown. We evaluated the significance of prior AGVHD on CGVHD presentation, overall response and survival in a contemporary cohort of CGVHD patients prospectively enrolled by the CGVHD consortium. Cases enrolled in the consortium could be incident (enrollment < 3 months after diagnosis) or prevalent (enrollment ≥3 months after diagnosis).10 Detailed CGVHD assessments were performed reflecting the recommendations of the NIH Consensus Conference,9,13 and are published in the cohort study rationale and design summary.10 Prior AGVHD was considered present if maximum grade I-IV was reported. Comparisons were performed between two groups: Prior AGVHD and no prior AGVHD. Statistical comparisons between groups were made with the two-sample t-test for continuous variables, and chi-squared test for categorical variables. Spearman correlation coefficients (ρ, rho) and simple kappa statistics were used to describe rank correlation and agreement between acute and CGVHD overall severity scores and skin, GI, and liver severity. Survival was estimated by the Kaplan-Meier method.14 Overall survival was calculated from enrollment, and non-relapse mortality (NRM) was defined as death without prior relapse. Failure-free survival (FFS) was defined as survival without prior relapse or adding new systemic medications to treat CGVHD. Cox regression15 was used for multivariate analysis of survival relative to presence or absence of prior acute GVHD and other risk factors. The total cohort included 496 patients: 329 with prior AGVHD and 167 with no prior AGVHD (de-novo CGVHD) (table 1). The prior AGVHD and de-novo CGVHD groups did not differ with respect to time between HCT and CGVHD diagnosis, or time between HCT and enrollment. The proportion of patients with classic and overlap CGVHD and the distribution of CGVHD global severity (mild, moderate and severe CGVHD), using clinician or patient reported and NIH scores, was similar. These observations support the hypothesis that CGVHD in patients with prior AGVHD does not differ fundamentally from de-novo CGVHD. In particular, prior AGVHD was not associated with AGVHD manifestations at the time of CGVHD diagnosis (overlap syndrome). There were some differences between prior AGVHD and de-novo CGVHD groups: Myeloablative conditioning, a mismatched or unrelated donor, and thrombocytopenia were more frequent in those with prior AGVHD. No further differences were observed between the two groups, including frequency of organ involvement, functional assessments or patient reported outcomes. Table 1 Patient and CGVHD characteristics

Graft-versus-Tumor Effect According to Type of Graft-versus-Host Disease Defined by National Institutes of Health Consensus Criteria and Associated Outcomes

The impact of National Institutes of Health consensus criteria (NCC) graft-versus-host disease (GVHD) on survival has rarely been investigated in a large cohort of patients with GVHD presenting before and after day 100 posttransplantation. We retrospectively investigated 775 patients who underwent allogeneic stem cell transplantation and assessed the GVHD effects on survival by the time-dependent covariates in Cox proportional hazards regression models. Using the NCC, the patients were classified into 4 groups: (1) no GVHD (n= 251); (2) acute GVHD (aGVHD) only (n = 199), including 26 patients with late aGVHD; (3) classic chronic GVHD (cGVHD; n = 232); and (4) overlap syndrome (OS; n = 93). Multivariate analyses showed that classic cGVHD (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.27-0.77) and OS (HR, 0.52; 95% CI, 0.28-0.96) were associated with significantly decreased risk of relapse, whereas aGVHD only was not associated with relapse rate (HR, 1.11; 95% CI, 0.76-1.63). All aGVHD events, including the period of aGVHD in patients who developed cGVHD after aGVHD, also did not affect the risk of relapse (HR, 0.74; 95% CI, 0.49-1.12). All types of GVHD were significantly associated with higher nonrelapse mortality in common. Finally, patients with aGVHD only had significantly lower overall survival and disease-free survival compared with those without GVHD, in contrast to favorable survival outcomes in patients with cGVHD without previous aGVHD. This study demonstrates that NCC GVHD type is associated with different graft-versus-tumor effects. Further studies are needed to investigate risk factors, pathogenesis, and biomarkers for each type of NCC GVHD.

NIH-Defined Graft-Versus-Host Disease in Patients with Acute Lymphoblastic Leukemia: Natural History, Prognostic Impact and Effect of Donor Lymphocyte Infusions

Abstract 4547 Introduction:The 2005 NIH consensus criteria (NCC) for acute and chronic graft-versus-host disease (aGVHD, cGVHD) are the gold standard for classifying GVHD in trials but they are not routinely used in the clinic, in part due to uncertainty about their prognostic value. To address this limitation we analyzed NIH-defined GVHD in 147 consecutive acute lymphoblastic leukemia (ALL) patients who received a first myeloablative transplant at our center between 1995 and 2009. Methods:Median age was 31 years (range: 17–56). Disease status was CR1 (50%), CR>1 (22%) or no CR (28%). Myeloablative conditioning consisted of 12 Gy TBI ± etoposide ± cyclophosphamide. Donors were HLA-matched related (42%), -matched unrelated (46%) or -mismatched (12%) and peripheral blood stem cells (74%) or bone marrow (26%) were given. GVHD-prophylaxis consisted of CSA/MTX (72%), CSA/prednisolone (19%) or other CSA-based regimens (9%). ATG was given in HLA-mismatched transplants (12%) and since 2005 also in matched unrelated transplants (11%), according to GMALL study protocols. Preemptive donor lymphocyte infusions (DLI) were a treatment option in case of mixed chimerism or minimal residual disease. Results:Median follow-up was 60 months (8–185). Projected overall survival (OS) at 1, 2 and 5 years was 64%, 56% and 49%. 5-year cumulative incidence of relapse was 33% and of non-relapse mortality (NRM) 25% (7% infections, 9% aGVHD, 7% cGVHD, 2% other). Median time until onset of classic aGVHD was 20 days (5–95). Cumulative incidence of classic aGVHD was 41% for grade I/II and 29% for grade III/IV. Among patients with classic aGVHD, skin, liver or gut involvement was seen in 94%, 32% and 34%. Late aGVHD was observed in 12% at a median of 100 days (range 100–240). Among late aGVHD cases 82% were subclassified as persistent or recurrent classic aGVHD. Median time until onset of chronic GVHD was 115 days (14–294) measured from transplant or DLI with a cumulative incidence for mild, moderate and severe forms of 13%, 15% and 25%. Mouth, skin, eyes, liver, joints and fascia, gut, lung and other organs were involved in 91%, 70%, 61%, 48%, 27%, 19%, 10% and 6% of cGVHD cases. cGVHD was subclassified as classic cGVHD and overlap syndrome in 40% and 60% of cases. 62% had progressive or quiescent type of onset. In multivariate Cox regression analysis with GVHD as time-dependant covariate (table 1) classic aGVHD grade III/IV was associated with inferior OS due to higher NRM. Comparable effects were seen for late aGVHD. In contrast, moderate and severe cGVHD were associated with superior OS due to lower relapse incidence. Classic and overlap cGVHD had no differential prognostic impact. 34 patients without GVHD after cessation of immunosuppression received preemptive DLI. In this subgroup cumulative incidence of classic aGVHD, late aGVHD or cGVHD was 62%, 6% and 62%. Organ involvement was comparable to non-DLI associated GVHD. In a time-dependant multivariate analysis, patients who developed NIH-defined cGVHD after DLI had improved OS (HR 0.21, 95%CI: 0.054–0.81, P=0.023) due to lower relapse incidence (HR 0.26, 95%CI: 0.043–0.91, P=0.048) compared to patients without cGVHD after DLI. Conclusions:This is the first study on the natural history and prognostic impact of NIH-defined GVHD in ALL patients. We found that severe classic aGVHD leads to higher NRM and inferior OS with similar effects seen for late aGVHD. cGVHD had a positive impact on OS and relapse rate, both after transplant and after preemptive DLI, indicating a potent graft-versus-leukemia effect. Although our cohort contains some heterogeneity we believe that this data supports the use of the NCC as diagnostic and prognostic tool in ALL patients.OSRelapseNRMHRPHRPHRPaGVHD None Grade I/II Grade III/IV1 0.63 (0.34−1.15) 2.55 (1.48−4.40)0.13 0.0011 0.44 (0.22−0.90) 0.75 (0.33−1.71)0.024 0.491 0.97 (0.37−2.62) 5.85 (2.56−13.35)0.98 0.001Late aGVHD None Grade I/II Grade III/IV1 0.81 (0.25−2.63) 1.67 (0.70−3.97)0.73 0.251 0.51 (0.07−3.87) 0.66 (0.15−2.85)0.52 0.581 1.42 (0.32−6.19) 3.45 (1.16−10.45)0.65 0.026cGVHD None Mild Moderate Severe1 0.54 (0.21−1.36) 0.18 (0.05−0.60) 0.47 (0.23−0.94)0.19 0.005 0.0321 0.52 (0.13−2.04) 0.34 (0.10−1.13) 0.14 (0.04−0.44)0.35 0.078 0.0011 0.69 (0.18−2.66) 0.18 (0.02−1.43) 0.69 (0.24−1.98)0.59 0.11 0.49Multivariate Cox regression analysis for OS, relapse and NRM with GVHD as time-dependant covariate. Only results for GVHD are shown. Disclosures:No relevant conflicts of interest to declare.