Recipients Of Allogeneic Grafts Research Articles

Evaluating Risk Factors and Outcomes For Clostridium Difficile Infection (CDI) In Stem Cell Transplant (SCT) Recipients

IntroductionClostridium difficile infections (CDI) are the leading cause of infectious diarrhea among pts undergoing stem cell transplantation (SCT). Data from large pt samples evaluating the trends, risk factors, hospitalization outcomes are lacking. We have analyzed the Nationwide Inpt Sample (NIS) database to evaluate the trends in the incidence and the impact of CDI on hospitalization outcomes among SCT recipients. MethodsWe used the NIS database to obtain the hospitalization data for primary procedures of autologous and allogeneic SCT between 01/2001 until 12/2010. We performed separate multivariate logistic regression analyses to evaluate risk factors of CDI in SCT pts and hospitalization outcomes including length of stay (LOS), in-hospital mortality (IHM) and hospitalization charges. Comorbidites were identified using software that created measures reported by Elixhauser et al. ResultsThe incidence of CDI among transplant pts has remained relatively stable over time (Fig 1), with a higher cumulative incidence of CDI among recipients of allogeneic grafts (allogeneic vs. autologous SCT: 8.29% vs. 5.63%; p<0.001). There was an association between CDI and the presence of multiple comorbidities among autologous SCT pts (p=0.05), and a similar trend was seen in allogeneic transplant pts. Mean LOS (CDI vs. none: autologous 26 vs. 20 days, p<0.0001; allogeneic 42 vs 30 days, p<0.001; respectively), IHM (CDI vs. none: autologous, 4.0 vs. 2.2%, p=0.0003; allogeneic 12.7 vs 9.2%, p=0.0008) and mean hospitalization charges (CDI vs. none: autologous $208,025 vs. $145,250, p<0.0001; allogeneic $367,415 vs $270,366 p<0.0001; respectively) were significantly higher among SCT pts with CDI (Table 1). [Display omitted] Table 1Pt characteristics, multivariate regression models for evaluating risk and outcomes of SCT pts with CDIAutologous SCTAllogeneic SCTCDI (%) (N=3772)SCT patients (%) (N=63202)p-valueCDI (%) (N=3440)SCT patients (N=38066)p-valueMean age (SE)54.3 (0.52)52.02 (0.27)<0.000145.07 (0.64)46.57 (0.38)<0.0098Male2311 (61.3)37038 (58.6)0.15962188 (63.6)21906 (57.6)0.0005White2369 (77.4)26124 (74.3)0.10892199 (77.7)23695 (78)0.847Comorbidities ≥12945 (78)46872 (74.2)0.052607 (75.8)27712 (72.8)0.1073Medicare945 (25.1)12460 (19.8)<0.0001310 (9.0)4111 (10.8)0.183Medicaid330 (8.8)6818 (10.8)0.1161474 (13.8)3996 (10.5)0.0126Private Insurance2320 (61.6)40209 (63.8)0.24832486 (72.4)27601 (72.7)0.8798Mean LOS (SE)*26 (0.71)20 (0.27)<0.0001*42 (1.59)30 (0.68)<0.0001*IHM152 (4.0)1330 (2.1)0.0003438 (12.7)3360 (8.8)0.0008Charge Mean (SE)208025 (8370.6)145250 (4311.3)<0.0001*$367415 (15033)$270366 (11835)<0.0001*Multivariate logistic regression model evaluating risk of CDI in SCT patientsVariableOdds RatioRefp-valueOdds RatioRefp-value≥651.4 (0.987-1.985)Age <40 (Ref)0.19450.637 (0.426-0.953)0.0834Male1.25 (1.054-1.483)Female (Ref)0.01031.351 (1.157-1.576)Female (Ref)0.0001Medicare1.149 (0.878-1.502)Private (Ref)0.04390.85 (0.581-1.244)Private (Ref)0.4605Medicaid0.887 (0.642-1.226)0.76731.269 (0.920-1.749)0.0272No Comorbidities0.831 (0.650-1.063)Comorbidities ≥10.14060.829 (0.672-1.024)Comorbidities ≥10.082 ConclusionsThe incidence of CDI among both autologous and allogeneic SCTs have remained stable over the last decade, with a slightly higher risk among allogeneic SCT pts. CDI was associated with longer hospital stay, higher charges and higher IHM for both autologous and allogeneic transplant pts. While this analysis does not permit us to directly ascribe differences in outcome to CDI alone, these data suggest that CDI has a major morbid impact in the setting of SCT, and provides a rationale for development of more effective approaches for prevention of CDI in these pt populations. Disclosures:Kaufman:Onyx: Consultancy; Celgene: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Janssen: Consultancy; Millenium: Consultancy; Merck: Research Funding. Lonial:Millennium: Consultancy; Celgene: Consultancy; Novartis: Consultancy; BMS: Consultancy; Sanofi: Consultancy; Onyx: Consultancy.Multivariate logistic regression model evaluating hospitalization outcomes in SCT patients with CDI #CDIAbsencePresencep-valueCDIAbsencePresencep-valueLOS >19 days0.382 (0.31-0.466)1.00 (Ref)<0.0001LOS > 27 days0.337 (0.27-0.42)1.00 (Ref)<0.0001Charge > $125,0910.483 (0.40-0.58)<0.0001Charge > $22,60110.487 (0.38-0.67)<0.0001IHM0.68 (0.44-1.06)0.089IHM0.661 (0.50-0.87)0.0037SE: Standard error; *adjusted for age, race, sex, comorbidity and payer status.#Median LOS and charges used as cut-off for hospitalization outcomes

Split Tolerance in a Murine Model of Heterotopic En Bloc Chest Wall Transplantation.

Background:Congenital and acquired chest wall deformities represent a significant challenge to functional reconstruction and may impact feasibility of heart transplantation for patients with end-stage organ failure. In the recent past, the concept of replacing like-with-like tissue by using vascularized composite allografts (VCA) has been enthusiastically employed for reconstruction of complex tissue defects.Methods:In this study, we introduce a novel murine model for en bloc chest wall, heart, and thymus transplantation and thereby the use of complex tissue allografts for reconstruction of both chest wall defects and also end-stage organ failure. Additionally, this model allows us to study the features of combined vascularized bone marrow (VBM), thymus, and heart transplantation on allograft survival and function. Heterotopic chest wall, thymus, and heart transplants were performed in untreated syngeneic and allogeneic combinations and in allogeneic combinations treated with costimulation blockade (CTLA4-Ig and MR-1).Results:Indefinite (ie, 150 d, N = 3) graft survival was observed in syngeneic controls. In untreated recipients of allogeneic grafts, the skin component was rejected after 10 (±1) days, whereas rejection of the heart occurred after 13 (± 1) days (N = 3). Costimulation blockade treatment prolonged survival of the heart and chest wall component (130 d, N = 3) as well as the VBM niche as evidenced by donor-specific chimerism (average: 2.35 ± 1.44%), whereas interestingly, the skin component was rejected after 13 (±1) days.Conclusion:Thus, this novel microsurgical model of VCA combined with solid organ transplantation is technically feasible and results in split tolerance when treated with costimulatory blockade.

Venous Thromboembolism in Pediatric Hematopoietic Cell Transplant: A Multicenter Cohort Study

Hematopoietic cell transplant (HCT) is associated with a proinflammatory, procoagulant environment that places recipients at increased risk of venous thromboembolism (VTE). Although the incidence of VTE in adult HCT recipients has been extensively studied, similar data for children are lacking. We conducted a multicenter retrospective study to analyze the prevalence of VTE and associated risk factors in a large cohort of patients who underwent HCT at tertiary care US children's hospitals. The Pediatric Health Information System database, a large administrative database that contains clinical and resource utilization data from 49 freestanding children's hospitals in the United States, was used to extract data. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify HCT recipients, VTE events, post-HCT complications, and associated risk factors up to 1 year post-transplant. Data on patients who received HCT from January 2010 through September 2014 were collected. A total of 4158 unique patients mean ± standard deviation age at transplant admit, 8.8 ± 6.5 years; range, birth to 33.4 years) were identified. After HCT 290 subjects (6.9%) developed VTE. VTE prevalence was greater in patients aged ≥ 13 versus <13 years (8.54% versus 6.33%; P = .01) and in recipients of allogeneic versus autologous grafts (7.7% versus 5%; P ≤ .01). VTE was associated with prolonged median duration of hospitalization (81 versus 54 days; P ≤.01) and increased 1-year mortality (13.9% versus 5.9%; P ≤ .01). Infections and presence of any graft-versus-host disease (GVHD) were significantly associated with VTE occurrence in recipients of allogenic grafts. Prevalence of VTE in patients who underwent HCT at pediatric tertiary care hospitals is about 7%. Age ≥ 13 years and allogeneic grafts were significant pre-HCT VTE risk factors, with GVHD and infections seen more frequently in patients with VTE.

Hospital readmission following transplantation: identifying risk factors and designing preventive measures.

About 1 in 7 of all hospitalized patients is readmitted within 30 days of discharge. The cost of readmissions is significant, with Medicare readmissions alone costing the health care system an estimated $28 billion a year. To identify the rates of and causes for readmission within 100 days of patients receiving a hematopoietic stem cell transplant. We performed a retrospective review of 235 consecutive transplant recipients (autologous, n = 144; allogeneic, n = 91) to determine rates and causes for readmission within 100 days of patients receiving a transplant. Medical records and hospital readmissions were reviewed for each patient. 36 allogeneic patients accounted for 56 readmissions. 23 autologous patients accounted for 26 readmissions. Autologous transplant recipients were most commonly readmitted for the development of a fever (n = 15 patients) or cardiopulmonary issues (n = 4). The most prevalent reasons for readmission in the allogeneic recipients included a fever (n = 21) or the development or exacerbation of graft-versus-host disease (n = 5). The readmission length of stay was 6 days (median range, 1-91 days) for allogeneic patients and 4 days (median range, 1-22 days) for autologous patients. There was no difference in survival between the readmitted and the non-readmitted cohorts (𝑃 = .55 for allogeneic patients; 𝑃 = .24 for autologous patients). Although allogeneic graft recipients demonstrated a higher readmission rate (39.6%) compared with autologous recipients (16%), none of the variables examined, including age, gender, performance status, diagnosis, remission status at the time of transplant, comorbidities, type of preparative chemotherapy regimen or donor type, identified patients at increased risk for readmission. Variations in clinical care, physician practices, and patient characteristics need to be considered when examining readmission rates. Most of the allogeneic patient population included unrelated donor recipients (65%) who received nonmyeloablative conditioning regimens (81% of allogeneic recipients). These features may not be characteristic of other centers. In these high-risk patients, readmissions following a transplant are common. Enhanced predischarge education by nurses and pharmacists, along with ongoing outpatient education and rigorous outpatient follow-up through phone calls or social media may decrease readmission rates.

MicroRNA-182 is a key modulator of FOXO1 expression and induced in response to alloantigens during acute rejection

MicroRNAs (miRNAs) are small non-coding RNA molecules that regulate the post-transcriptional expression of target genes and have been shown to be important regulators of many biologic processes including innate and adaptive immune responses. The roles of specific miRNAs in alloimmune responses remain unknown. We used a mouse model of heart transplantation and microarray analysis to profile miRNAs differentially expressed during allograft rejection with the goal of identifying miRNAs that regulate alloimmune responses and graft outcomes. Syngeneic (C57BL/6 → C57BL/6) and allogeneic (BALB/c → C57BL/6) (n=3-9) heterotopic heart transplants were performed. Heart grafts were collected on days 1-7 and graft infiltrating lymphocytes (GILs) were isolated on day 5 post-transplant. Samples were profiled using TaqMan microfluidic cards that contain 335 mature mouse miRNAs. Microarray data were analyzed to define miRNAs that are differentially expressed (P< 0.05). Differentially expressed miRNAs were validated by Taqman miRNA assays using samples from additional groups (n=3-5) of transplanted mice. Sixteen miRNAs were significantly differentially expressed in both the heart grafts and the GILs of allogeneic recipients, compared to syngeneic recipients, including the miRNA miR-182, a dominantly expressed member of miR-183-96-182 cluster. Forkhead Box (FOX) proteins are a family of important transcription factors and FOXO1 is a predicted target of miR-182. We used a luciferase reporter assay system and confirmed FOXO1 is a target of miR-182 as mutation of the Foxo1 seed sequence decreased specific binding to miR-182. FOXO1 expression in grafts was analyzed by qPCR and western blot on days 1-5 post-transplant and immunohistochemistry was used to detect FOXO1 expression in cardiomyocytes and GILs. We show that as miR-182 increases after transplant, there is a concomitant post-transcriptional decrease in FOXO1 expression in heart allografts. Further FOXO1 expression is localized to both the cardiomyocytes and CD3+ T cells. Importantly, miR-182 was significantly increased in both the PBLs and plasma from recipients of allogeneic grafts as compared to recipients of syngeneic grafts and normal mice. These data indicate that miR-182 expression is specifically expressed in the circulation of graft recipients and suggest that since miRNAs are incredibly stable in blood, they will be important as biomarkers of graft status. Our results suggest that miRNAs may have important regulatory functions post-transplant.

Lymphoid Microrna Profiles During Allograft Rejection

MicroRNAs (miRNAs) are highly conserved non-coding RNAs that regulate gene expression by translational repression or by mRNA degradation. MiRNAs as immune regulators may govern expression of genes relevant to allograft rejection, tolerance induction and post-transplant infection in recipients of organ transplants. We performed a broad analysis on miRNAs expressed by lymphocytes that may regulate immune functions post-transplant. Groups of syngeneic (C57BL/6 → C57BL/6) and allogeneic (BALB/c →C57BL/6) recipients (n=3-9) of heterotopic heart transplants were performed and spleen, PBMC and graft infiltrating cells (GILs) were obtained for miRNA microarray analysis using TaqMan microfluidic cards. Data were analyzed using SDS and RQ software to define miRNAs that are differentially expressed (P< 0.05). Of the 335 mature mouse miRNAs examined, forty-four miRNAs were significantly differentially expressed in allogeneic GILs (P< 0.05) as compared to syngeneic GILs. Eleven (10 increased, 1 decreased) miRNAs were significantly changed in the spleen while ten (6 increased, 4 decreased) showed significant differential expression in PBMC. Interestingly five miRNAs, miRs-146a, 337-5p, 342-3p, 410 and 449a shared differential expression in both the PBMC and GILs and two miRNAs, miR-7a and miR-182 were significantly increased in PBMC, GILs and spleen. Experiments were performed to examine the kinetics of miR-182 expression by T cells in response to alloantigen. T cell proliferation and miR-182 expression were analyzed on days 1-5 in MLR using C57BL/6 responder T cells and BALB/c stimulator splenocytes. Maximal expression of miR-182 coincided with maximal proliferation on day 5. Treatment with the calcineurin inhibitor CsA markedly decreased the expression of miR-182 in T cells, while the expression of the housekeeping gene snoRNA135 remained stable. These results suggest that IL-2 may induce miR-182 expression. CD4+T cells are the likely source of miR-182 as mice deficient in CD8+ T cells (B6.129S2-Tap1tm1Arp/J) expressed miR-182 as similar levels as wild-type mice when used as recipients of BALB/c allografts. Since miR-182 is differentially expressed in the spleen, GILs and PBMC during graft rejection, we analyzed corresponding plasma samples for miR-182. There was a specific and significant increase in miR-182 in the plasma of the recipients of allogeneic grafts as compared to recipients of syngeneic grafts suggesting the potential as a biomarker of graft status. Taken together, our results suggest that lymphocyte-associated miRNAs may be novel targets for therapeutics to improve graft outcomes.

Cyclosporine immunosuppression does not prevent the production of donor-specific antibody capable of mediating allograft vasculopathy

Late cardiac graft rejection, primarily mediated by allograft vasculopathy (AV), remains a major limitation to cardiac transplantation, even in the face of significant calcineurin inhibitor (CNI) immunosuppression. The role played by alloantibody in AV is unclear. Evidence that CNI immunosuppression suppresses CD4(+) T-cell function would suggest that antibody production and effector function would be severely limited in CNI-treated patients. In this study we examine the capacity of CNI-treated animals to develop effective alloantibody that can mediate AV. Wild-type (WT) B6 mice were alloimmunized using donor splenocytes or a fully major histocompatibility complex-mismatched allogeneic abdominal aortic graft in the presence of CNI immunosuppression (30 or 50 mg/kg/day cyclosporine A). Anti-serum was harvested and tested using complement-dependent in vitro cytotoxicity assays. Anti-serum was passively transferred to immunodeficient RAG1(-/-) recipients of allogeneic grafts. C4d deposition was quantified in the allografts from WT recipients. CNI immunosuppression did not prevent the development of alloantibody in response to either immunization method (p < 0.05). Passive transfer of anti-serum generated AV lesions in immunodeficient graft recipients and mediated complement-dependent destruction of donor cells (p < 0.05). C4d deposition was localized to the media of grafts of CNI treated animals. CNI therapy does not prevent the production of alloantibody with the capacity to mediate AV. C4d deposition in the media suggests a role for medial smooth muscle cell loss in antibody-mediated AV lesion development in our model.

Cardiovascular Hospitalizations and Mortality Among Recipients of Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is increasingly used to treat multiple malignant and nonmalignant conditions. The risk for cardiovascular disease after the procedure has not been well-described. To compare rates and hazards of cardiovascular-related hospitalization and death among persons who were still alive at least 2 years after HSCT with those in a population-based sample. Retrospective cohort study. Comprehensive cancer center. 1491 patients who had survived 2 years or longer after HSCT received between 1985 and 2006, and frequency-matched persons who were randomly selected from drivers' license files in the state of Washington. Cardiovascular hospitalizations and death, as determined from statewide hospital discharge records and death registries in Washington. Compared with the general population, transplant recipients experienced increased cardiovascular death (adjusted incidence rate difference, 3.6 per 1000 person-years [95% CI, 1.7 to 5.5]). Recipients also had an increased cumulative incidence of ischemic heart disease, cardiomyopathy or heart failure, stroke, vascular diseases, and rhythm disorders and an increased incidence of related conditions that predispose toward more serious cardiovascular disease (hypertension, renal disease, dyslipidemia, and diabetes). No consistent differences in hazards were observed after total-body irradiation or receipt of an allogeneic versus an autologous graft, aside from an increased rate of hypertension among recipients of allogeneic grafts. Disease relapse after transplantation was associated with an increased hazard of cardiovascular death (hazard ratio, 2.3 [CI, 1.1 to 4.8]). All patients received HSCT at a single institution, and no information was available on pretransplantation treatment and lifestyle factors that may influence risk for cardiovascular disease. Increased rates of cardiovascular disease should be taken into account when caring for patients who have received HSCT. Future efforts should be directed toward improved screening and controlling of factors that predispose toward cardiovascular disease. The American Society for Blood and Marrow Transplantation, the Leukemia and Lymphoma Society, and the Seattle Children's Research Institute.

A Quality of Life Study Utilizing the EORTC QLQ-30 and EORTC QLQ-HDC29 Questionnaires for the Interview of 215 Patients Who Received Autologous or Allogeneic Hematopoietic Stem Cell Transplantation.

Abstract 2470Poster Board II-447The continued optimizations of hematopoietic stem cell transplantation (HSCT) protocols and improved donor selection criteria have made HSCT available for a growing number of patients. Although, patients receive HSCT as treatment for a potentially life-threatening disease, the procedure itself, especially in the allogeneic setting, is also potentially life-threatening and we know little about the impact of this profound procedure on the long-term quality of life in transplant recipients.To get a comprehensive insight, we mailed the standardized questionnaires EORTC QLQ-C30 (version 3.0) and the supplementary module EORTC QLQ – HDC29 to 291 patients who were treated between 1989 and 2007 at our facility and maintain a complete remission. Patients had the opportunity to contact the principle investigator to address any questions that may arise. In total, 229 (78%) patients responded, of which 8 (3%) patients refused participation. Of the remaining 221 patients, 215 were eligible for analysis. Participants median age at the time of response was 53 years (range 26-71) and 105 (49%) were female. The median time between diagnosis and transplant was 293 days (range 40 – 5489) and the median time between transplant and interview was 6 years (range 1.3 – 18.4). Primary diagnoses of analyzed patients were as follows: 104 (48%) Non-Hodgkin Lymphoma; 48 (22%) Acute Myeloid Leukemia; 13 (6%) Acute Lymphoblastic Leukemia; 21 (9%) Chronic Myelogenous Leukemia; 11 (5%) Myelodysplastic Syndrome; 4 (2%) Multiple Myeloma; 7 (3%) Aplastic Anemia; 5 (2%) Osteomyelofibrosis; 2 (1%) Chronic Lymphocytic Leukemia. Overall, 120 patients (56%) received an allogeneic and 95 patients (44%) received an autologous graft, which were derived from peripheral blood stem cells in 192 (89%) cases and derived from bone marrow in 20 (9%) cases. The stem cell source remained unknown for 3 (1%) patients. Of the 120 allogeneic grafts, 47 (39%) were donated by a matched unrelated donor, whereas 71 (59%) were donated by a matched sibling donor and in 2 (1%) cases information about the type of donor were not available.In general, 148 (69%) of the 215 patients reported a subjectively good to very-high quality of life (Scores 5-7), whereas 145 (67%) patients described their health as good to excellent (Scores 5-7). For now, we focused our analysis on differences between patients who received an autologous, and those who received an allogeneic graft. A significant difference was reported for 2 of the 30 parameters of the QLQ - C30 and for 4 of the 29 parameters of the QLQ – HDC29. Patients who received an allograft were more affected by shortened breath (p = 0.028) and cognitive difficulties (p = 0.019). Furthermore, these patients were more upset about how the treatment affected their hair with a higher proportion of females in this group. Also, parameters which are associated with the higher risk of disease und transplant procedure like worrying about test results and fears to share concerns with family and friends, were more exaggerated in patients who received an allograft. With regard to social integration, affection of family life or sexual interest and the ability to enjoy sexual contacts, no differences were found between these two patients groups. The same is true for the overall perfomance levels in daily life. Despite the higher toxicity of allogeneic HSCT and the fact that more recipients of allogeneic grafts were on continued medication, a significantly higher proportion (51%) was working in his or her old job, when compared to patients who received an autologous transplant (34%). When we looked at gender specific differences independent from the type of transplant, female patients reported a significantly lower sexual interest (p = 0.001) and a significantly lower ability to enjoy sexual contacts (p = 0.041) than male patients. Only 48 females reported an average to high ability to enjoy sexual contacts in contrast to 70 male patients. An average to high interest in sex was reported by only 6 females, compared to 30 males with an almost equal distribution of male and female patients in our study. Still, males and females reported similar scores for their overall quality of life, quality of their relationship and social integration. These findings suggest that HSCT has a profound impact on the sexual life of female patients, and consequently their partners. For future works, it might be worth to include questionnaires for partners and maybe even children to get unbiased, concise data on the quality of life after HSCT. Disclosures:No relevant conflicts of interest to declare.

Diffuse alveolar hemorrhage after unrelated cord blood transplantation

Diffuse alveolar hemorrhage (DAH) is a recognized pulmonary complication in the setting of hematopoietic STC (HSCT). DAH after HSCT is often fatal, but the exact etiology remains unclear. DAH after HSCT is reported in 1–5% of autologous graft recipients and in 3–7% of allogeneic graft recipients.1, 2, 3, 4 Umbilical cord blood transplantation (CBT) from unrelated donors has recently increased in popularity for adult patients with hematological diseases who have no other suitable donor. However, DAH in the setting of post CBT has not been discussed in detail.4 We describe herein, a case of a patient with DAH after CBT who was successfully treated with relatively low-dose steroid therapy using prednisolone at 1 mg/kg/day.

Multiple viral infections post-hematopoietic stem cell transplantation are linked to the appearance of chronic GVHD among pediatric recipients of allogeneic grafts

Delayed immune reconstitution and the ensuing opportunistic infections among children following hematopoietic stem cell transplantation (HSCT) are associated with increased treatment-related morbidity and mortality (TRM). We retrospectively evaluated the impact of viral infections on the posttransplant recovery of pediatric recipients of stem cell grafts as a reflection of their posttransplant immunoreconstitution in a single institution setting. The case histories of 124 children (during 1/1999-9/2006) were reviewed for infectious episodes, and correlated with their respective clinical parameters. Patients with a high risk for CMV received prophylaxis, but failures in the prophylaxis were common (40%). 110/124 (89%) of these allogeneic patients had at least one viral reactivation/clinical infection posttransplant. In this group of pediatric patients chronic GVHD (P<0.001) and secondary graft failure were significantly (P=0.001) associated with early (during the first 100 days post HSCT), multiple (> or = 2) viral infections. Our data indicate that viruses are common pathogens among pediatric recipients of allogeneic stem cell grafts. In this group of patients multiple viral infections early on seem to reflect an even more severe degree of immunological derangement in the recipient and identify a group of patients with an increased risk of chronic GVHD and secondary graft failure.

Prognostic Factors for Leukemic Induction Failure in Children With Acute Lymphoblastic Leukemia and Outcome After Salvage Therapy: The FRALLE 93 Study

To identify prognostic factors and to evaluate the outcome of children with acute lymphoblastic leukemia (ALL) failure after induction therapy. Between June 1993 and December 1999, 1,395 leukemic children were included in the French Acute Lymphoblastic Leukemia 93 study. Fifty-three patients (3.8%) had a leukemic induction failure (LIF) after three- or four-drug induction therapy. In univariate analysis, high WBC count (P = .001), mediastinal mass (P = .017), T-cell phenotype (T-ALL; P = .001), t(9;22) translocation (P = .001), and a slow early response (at day 8 and/or on day 21, P = .001) were predictive of LIF. The following three prognostic groups for LIF were identified by multivariate analysis: a low-risk group with B-cell progenitor (BCP) ALL without t(9;22) (odds ratio [OR] = 1), an intermediate-risk group with T-ALL and a mediastinal mass (OR = 7.4, P < .0001), and a high-risk group with BCP-ALL and t(9;22) or T-ALL without a mediastinal mass (OR = 28.4, P < .0001). Complete remission (CR) was subsequently obtained in 43 patients (81%). The 5-year overall survival (OS) rate of the 53 patients was 30% +/- 6%. The 5-year OS rate among allogeneic graft recipients, autologous graft recipients, and after chemotherapy were 30.4% +/- 9.6% (50% +/- 26% after genoidentical transplantation), 50% +/- 17.7%, and 41.7% +/- 14.2%, respectively (P = .18). Fourteen patients (26%) were still in first CR after a median of 83 months (range, 53 to 117 months). Three risk categories for LIF in children with ALL were identified. Approximately one third of patients with LIF can be successfully treated with salvage therapy overall. Subsequent CR after LIF is mandatory for cure.

7: Preservation of Pulmonary Diffusing Capacity with Oral Beclomethasone Dipropionate: Results From Two Randomized, Placebo-Controlled Trials in Allogeneic Graft Recipients

7: Preservation of Pulmonary Diffusing Capacity with Oral Beclomethasone Dipropionate: Results From Two Randomized, Placebo-Controlled Trials in Allogeneic Graft Recipients

Acute allograft rejection and immunosuppression: influence on endogenous melatonin secretion

Melatonin displays a dose-dependent immunoregulatory effect in vitro and in vivo. Exogenous high-dose melatonin therapy exerted an immunosuppressive effect, abrogating acute rejection (AR), significantly prolonging transplant survival. Endogenous melatonin secretion, in response to heterotopic rat cardiac allograft transplantation (Tx), was investigated during the AR response and under standardized immunosuppressive maintenance therapy with cyclosporin A (CsA) and rapamycin (RPM). Recipients of syngeneic transplants, and recipients of allogeneic grafts, either untreated or receiving immunosuppressive therapy constituted the experimental groups. Endogenous circadian melatonin levels were measured at 07:00, 19:00, and 24:00 hr, using a novel radioimmunoassay (RIA) procedure, under standardized 12-hr-light/dark-conditions (light off: 19:00 hr; light on: 07:00 hr), before and after Tx. Neither the operative trauma, nor the challenge with a perfused allograft or the AR response influenced endogenous melatonin peak secretion. Immunosuppressive therapy with CsA led to a significant increase in peak secretion, measured for days 7 (212 +/- 40.7 pg/mL; P < 0.05), 14 (255 +/- 13.9 pg/mL; P < 0.001), and 21 (219 +/- 34 pg/mL; P < 0.01) after Tx, as compared with naïve animals (155 +/- 25.8 pg/mL). In contrast, treatment with RPM significantly decreased the melatonin peak post-Tx up to day 7 (87 +/- 25.2 pg/mL; P < 0.001), compared with naïve animals (155 +/- 25.8 pg/mL). These findings imply a robust nature of the endogenous circadian melatonin secretion kinetics, even against the background of profound allogeneic stimuli. Immunosuppressive maintenance therapy with CsA and RPM modulated early melatonin secretion, indicating a specific secondary action of these drugs. Further studies are necessary to disclose the long-term effect of immunosuppressive therapy on circadian melatonin secretion in transplant recipients.

Streptococcus pneumoniae Infections in 47 Hematopoietic Stem Cell Transplantation Recipients

Streptococcus pneumoniae infections can cause serious systemic disease in patients following hematopoietic stem cell transplantation (HSCT), and the response to pneumococcal vaccine is inadequate in most HSCT recipients. We evaluated the clinical spectrum of pneumococcal disease and vaccine-breakthrough infections in HSCT recipients at our cancer center in a retrospective analysis of all consecutive episodes of S. pneumoniae infection from 1989 through 2005. During the study period, 7888 patients underwent HSCT at our center; we identified 47 HSCT recipients with 54 S. pneumoniae infections. The overall incidence of S. pneumoniae infection was 7 per 1000 HSCTs. The incidence was higher in recipients of allogeneic grafts than in recipients of autologous grafts (9 vs. 5 per 1000 HSCTs, respectively; p <or= 0.012). Thirty-two of the 47 patients (68%) had leukemia or lymphoma; 24 patients (51%) had a malignancy that was in complete remission. Seventeen patients (36%) had graft-versus-host disease, which was chronic in 16. The 54 episodes of S. pneumoniae infection occurred 433 +/- 669 days after HSCT; 5 patients (11%) had multiple episodes. Four episodes of S. pneumoniae infection occurred within 100 days following transplantation (45 +/- 49 d); 2 of these were during the pre-engraftment period and 3 were nosocomial infections. All 50 late post-transplant episodes (93%), which occurred 473 +/- 671 days following transplantation, were community-acquired infections (p < 0.00016). Thirty-three episodes (61%) presented as bacteremic pneumonia, 10 (19%) as pneumonia, and 8 (15%) as uncomplicated S. pneumoniae bacteremia alone. Logistic regression analysis showed that patients receiving systemic corticosteroids had increased risk for bacteremic pneumonia (odds ratio [OR], 11.7; 95% confidence intervals [CI], 1.371-99.280; p <or= 0.025). Patients with lymphoma (OR, 6.101; 95% CI, 1.106-33.640; p <or= 0.04) were more likely to develop pneumonia alone. In 27 episodes (93%) among 29 in which S. pneumoniae susceptibility testing was performed, the patients received concordant antimicrobials. Among the 6 patients (13%) who died of S. pneumoniae infection, 4 had S. pneumoniae bacteremic pneumonia and only 1 had chronic GVHD. Admission to a critical care unit at the onset of infection (OR, 15.5; 95% CI, 2.116-113.541; p <or= 0.007) and each unit increase in APACHE II score increase the probability of death (OR, 1.9; 95% CI, 1.181-3.054; p <or= 0.008). All 5 (11%) patients who developed vaccine-breakthrough S. pneumoniae infection (546 +/- 732 d following vaccination) had pneumonia, and in 4 patients concurrent bacteremia also occurred. A serious S. pneumoniae infection in HSCT recipients occurred more commonly in patients with lymphoma and patients receiving high-dose systemic corticosteroid therapy. It is noteworthy that there were no cases of extrapulmonary organ infection in HSCT recipients who presented with S. pneumoniae infection at our institution.

Nuclear Translocation of RelB within Host and Donor Antigen Presenting Cells Is Critical for the Initiation and Maintenance of Acute Graft-Versus-Host Disease.

Either donor or host antigen presenting cells (APC) are sufficient for the initiation of CD4 dependent graft versus host disease (GVHD). However the molecular transcription pathways within APC required for this effect are unknown. The NF-kB/Rel family member RelB is associated with dendritic cell (DC) maturation and is critical for the induction of potent APC function. DC from RelB−/− mice had markedly reduced levels of CD40 and to a lesser extent CD80/CD86 following in vitro activation. Following total body irradiation, the number of residual splenic DC with nuclear RelB was increased 5-fold relative to untreated mice. We therefore examined the role of RelB within donor and host APC in GVHD utilizing two well established bone marrow transplant models of CD4-dependant GVHD. To study the requirement of RelB within host APC we generated chimeric mice by transplanting wild-type (wt) or RelB−/− B6 bone marrow into irradiated wt B6 mice. Following immune reconstitution 4–6 months later, the number and frequency of DC (CD11chi and CD11cdimB220+) was equivalent in RelB−/− and RelB+/+ chimeras, although RelB−/− chimeras were specifically deficient in CD11chiCD4+ DC. Chimeras were subsequently transplanted with allogeneic Balb/c bone marrow and purified T cells. The absence of RelB within host APC significantly improved survival (survival day 60: 83% v 19%, P< .0001) and GVHD clinical scores were significantly reduced in RelB−/− chimeras for the first 4 weeks after transplant but subsequently rose to levels equivalent to those in surviving RelB+/+ chimeras. All RelB−/− and RelB+/+ chimeras that received syngeneic grafts survived without clinical evidence of GVHD. Sera from RelB−/− chimera recipients of allogeneic grafts contained reduced IFNg (117 ± 23 vs 253 ± 45 pg/ml; P< 0.02) and increased IL-5 (358 ± 105 vs 112 ± 20 pg/ml; P<0.05) compared to RelB+/+ chimera recipients (mean ± SE). Furthermore, CD4 T cells purified from the spleens of RelB−/− chimera recipients produced 2.6 fold more IL-4 (451 ± 31 vs 168 ± 17 pg/ml; P=0.01) than those from RelB+/+ chimera recipients. Taken together these data suggest the absence of nuclear RelB translocation within host APC abrogates GVHD and this is associated with the induction of donor Th2 differentiation. To study the role of RelB within donor APC we transplanted wt or RelB−/− B6 bone marrow and wt purified T cells into irradiated B6D2F1 recipients. In this model, GVHD severity was identical for the first 4 weeks after transplant but subsequently GVHD clinical scores in the recipients of RelB−/− donor APC returned toward levels seen in syngeneic recipients (clinical scores at day 49: 1.0 ± 0.6; n=6 vs 3.75 ± 0.4; n=6; RelB−/− vs RelB+/+P=0.01). This attenuation of acute GVHD in recipients of RelB−/− donor-derived APC was associated with the reconstitution of donor DC on day 21. These data suggest the inhibition of the nuclear RelB translocation within APC represents a potential new therapeutic target for the prevention of allograft rejection and GVHD.

Enhanced in situ expression of NF- κBp65 is an early marker of intestinal graft rejection in rats

Background Although intestinal transplantation provides a unique situation of free access to the graft because of the presence of temporary enterostomas, evaluation of local immunosuppression is still an unresolved issue and may constitute one of the causes of grafting failure. Aims To study in a rat model of allogeneic intestinal transplantation the expression of transcription factors involved in lymphocyte activation in situ in the graft and to identify factors reflecting the efficiency of drug immunosuppression. Methods Intestinal transplantation was performed in a Brown Norway (RT1 n-donors)–Lewis (RT1 l-recipients) rat strain combination. The animals were treated with tacrolimus to induce tolerance or left untreated. Syngeneic intestinal grafts and intestine from donor rats with peritonitis were used as controls. NF- κBp65, p-c-Jun, interleukin 2 receptor (CD25), and major histocompatibility complex class II antigen (OX-6) expression was studied in graft biopsies on days 2 and 5 by immunohistochemistry. Results On day 2, before the onset of histologic signs of rejection, the number of cells expressing NF- κBp65 in the pericryptic lamina propria was significantly higher in untreated recipients of allogeneic grafts than in the other groups ( P = .009). NF- κBp65 expression then fell between days 2 and 5 ( P = .009). Classic markers of T-cell activation (CD25 and OX-6) were expressed during rejection in the lamina propria and on crypt enterocytes, respectively. p-c-Jun expression did not differ among the 3 groups. Conclusion NF- κBp65 expression in intestinal grafts is a precocious sign of local activation during rejection and could thus serve to optimize the management of immunosuppressive therapy.

Short-term immunosuppression after rat parathyroid allotransplantation.

The aim of this study was to evaluate whether short-term postoperative immunosuppression is able to sufficiently prolong graft survival after experimental allogeneic parathyroid transplantation. Heterotopic parathyroid transplantation was performed in 6 groups: 1) syngeneic control Lewis (LEW) to LEW; 2) allogeneic control Wistar-Furth (WF) to LEW; 3-5) WF to LEW plus short-term immunosuppression, postoperative days 1-13 (cyclosporine 5/10/20 mg/kg); and 6) WF to LEW plus 10 mg/kg CyA from preoperative day 7 to postoperative day 7. Graft function was examined up to 60 days; histological and immunohistological examination was performed on all grafts with impaired function. Graft function after syngeneic transplantation was indefinite, while recipients of allogeneic grafts turned hypocalcemic after 13 +/- 2 days. With immunosuppression, graft function was 21 +/- 2 days (groups 5 and 6) and 28 +/- 3 days (groups 3 and 4). Histologically, a cellular infiltrate responsible for graft destruction was found. The results show that indefinite parathyroid allograft survival cannot be achieved by short-term immunosuppression alone. Whether the combination of an additional graft pretreatment and immunosuppression has an impact on graft function will be further examined.

Improvements in early behavior of rat kidney allografts after treatment of the brain-dead donor.

To improve the quality of organs from brain-dead donors by assessing the influence of alternative strategies on the early behavior of kidneys after transplantation into unmodified hosts. Kidneys transplanted from living donors perform consistently better than those from cadaver sources. The authors have recently shown that donor brain death produces inflammatory changes in peripheral organs within hours, amplifies coincident ischemia-reperfusion injury, and accelerates acute and chronic rejection. Normalization of the graft by donor hormone treatment has hitherto been unsuccessful. A standardized rat model of brain death was used. Experimental groups included recipients of allogeneic grafts from living and brain-dead donors (F344-->LEW). Donors were treated immediately after induction of brain death either with intravenous steroids, which block inflammatory cytokine release, or a soluble P-selectin glycoprotein ligand (sPSGL), which blocks initial selectin-mediated cellular adhesion. Kidney grafts were examined serially up to 10 days by morphology, immmunohistology, and reverse transcriptase-polymerase chain reaction. Overall survival of ummodified recipients of kidneys from brain-dead donors was significantly reduced versus living donors. Animals with organs from brain-dead donors that had received steroids or sPSGL survived significantly longer than those from untreated brain-dead donors. The intensity of ischemia-reperfusion injury and of acute rejection was reduced. Cellular infiltration and transcription of mRNA of representative proinflammatory mediators were diminished. Treatment of organ donors at the time of brain death markedly improves organ quality after kidney transplantation, upgrading it to that from a living donor.

Identification of the T cell clones expanding within both CD8(+)CD28(+) and CD8(+)CD28(-) T cell subsets in recipients of allogeneic hematopoietic cell grafts and its implication in post-transplant skewing of T cell receptor repertoire.

We have previously reported that skewed repertoires of T cell receptor-beta chain variable region (TCRBV) and TCR-alpha chain variable region (TCRAV) are observed at an early period after allogeneic hematopoietic cell transplantation. Furthermore, we found that T lymphocytes using TCRBV24S1 were increased in 28% of the recipients of allogeneic grafts and an increase of TCRBV24S1 usage was shown to result from clonal expansions. Interestingly, the arginine residue was frequently present at the 3' terminal of BV24S1 segment and was followed by an acidic amino acid residue within the CDR3 region. These results suggest that these clonally expanded T cells are not randomly selected, but are expanded by stimulation with specific antigens. This study was undertaken to elucidate the mechanisms of the post-transplant skewing of TCR repertoires. Since the CD8(+)CD28(-)CD57(+) T cell subset has been reported to expand in the peripheral blood of patients receiving allogeneic hematopoietic cell grafts, we examined the TCRAV and TCRBV repertoires of the CD8(+)CD28(-) T cell and CD8(+)CD28(+) T cell subsets, and also determined the clonality of both T cell populations. In all three recipients examined, the CD8(+)CD28(-) T cell subset appeared to define the post-transplant TCR repertoire of circulating blood T cells. Moreover, the CDR3 length of TCRBV imposed constraints in both CD8(+)CD28(-) T cell and CD8(+)CD28(+) T cell subsets. The DNA sequences of the CDR3 region were determined, and the same clones were identified within both CD8(+)CD28(-) and CD8(+)CD28(+) T cell subsets in the same individuals. These results suggest that the clonally expanded CD8(+)CD28(-) T cells after allogeneic hematopoietic cell transplantation derive from the CD8(+)CD28(+) T cell subset, possibly by an antigen-driven mechanism, resulting in the skewed TCR repertoire.