Steroid-resistant aGVHD Research Articles

Effect Analysis of 33 Patients with Corticosteroids Resistant Grade III/IV Acute Liver Graft-Versus-Host Disease Treated with Sequential Low-Dose Cyclophosphamide and Anti-Thymocyte Globulin Following Plasma Exchange

Background Acute graft-versus-host disease (aGVHD) represents a significant complication and leading cause of mortality in allo-HSCT. The response rate to corticosteroids is approximately 50%, with poor long-term survival observed in individuals with steroid-resistant (SR) aGVHD. Plasma exchange stands as the primary treatment for patients experiencing acute liver failure. Cyclophosphamide and anti-thymocyte globulin (ATG) function to inhibit lymphocyte activity in vivo. Currently, there are no clinical studies validating the efficacy of plasma exchange followed by low-dose cyclophosphamide and ATG for the treatment of liver Grade III/IV SR aGVHD. Methods A retrospective analysis was performed on 33 hematological patients who developed liver grade III/IV aGVHD after allo-HSCT in Henan Cancer Hospital from October 2020 to March 2024 and were treated with sequential low-dose cyclophosphamide and anti-thymocyte globulin after plasma exchange. Cyclophosphamide dose: 400 mg/ time for adults and children weighing ≥35 kg, 200mg/ time for children weighing < 35 kg, immediately after the end of plasma exchange. Anti-thymocyte globulin dose: adults and children weighing ≥35 kg 50mg/ time, children weighing < 35 kg 25mg/ time, immediately after the end of cyclophosphamide. Efficacy was evaluated 28 days after the first plasmapheresis. Results Among the 33 patients, 19 were males (57.6%) and 14 were females (42.4%). The median age was 29 (5-57) years.There were 9 cases (27.3%) of typical aGVHD and 24 cases (72.7%) of delayed aGVHD. There were 27 patients (81.8%) with grade III liver aGVHD and 6 patients (18.2%) with grade IV liver aGVHD. 15 patients (45.5%) achieved complete response (CR), 9 patients (27.3%) achieved partial response (PR), and 9 patients (27.3%) achieved no response (NR). The overall response rate (ORR) was 72.7% (24/33). After a median follow-up of 100 (6-1344) days, the overall survival (OS) rate of the 33 patients at 6 months after treatment was 42.8% (95%CI 25.4%-60.2%), and the OS rate at 1 year after treatment was 35.9% (95%CI 18.8%-53.0%). The OS rates of CR group, PR group and NR group at 6 months after treatment were 69.2% (95% CI 36.1%-86.3%) ,44.4% and 0, respectively. One year after treatment, the OS rates were 52.7% (95%CI 25.1%-80.3%), 44.4% (95%CI 11.9%-76.9%), 0, respectively, and the difference was statistically significant among the three groups (χ2 = 4.474, P < 0.001). Conclusions Sequential low-dose cyclophosphamide and anti-thymocyte globulin after plasma exchange may be an effective treatment for patients with corticosteroids resistant liver grade III/IV aGVHD.

Mesenchymal stromal/stem cells promote intestinal epithelium regeneration after chemotherapy-induced damage

BackgroundAllogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for leukemia and a range of non-malignant disorders. The success of the therapy is hampered by occurrence of acute graft-versus-host disease (aGvHD); an inflammatory response damaging recipient organs, with gut, liver, and skin being the most susceptible. Intestinal GvHD injury is often a life-threatening complication in patients unresponsive to steroid treatment. Allogeneic mesenchymal stromal/stem cell (MSC) infusions are a promising potential treatment for steroid-resistant aGvHD. Data from our institution and others demonstrate rescue of approximately 40–50% of aGvHD patients with MSCs in Phase I, II studies and minor side effects. Although promising, better understanding of MSC mode of action and patient response to MSC-based therapy is essential to improve this lifesaving treatment.MethodsSingle cell human small intestine organoids were embedded in Matrigel, grown for 5 days and treated with busulfan for 48 h. Organoids damaged by treatment with busulfan or control organoids were co-cultured with 5000, 10,000, and 50,000 MSCs for 24 h, 48 h or 7 days and the analyses such as surface area determination, proliferation and apoptosis assessment, RNA sequencing and proteomics were performed.ResultsHere, we developed a 3D co-culture model of human small intestinal organoids and MSCs, which allows to study the regenerative effects of MSCs on intestinal epithelium in a more physiologically relevant setting than existing in vitro systems. Using this model we mimicked chemotherapy-mediated damage of the intestinal epithelium. The treatment with busulfan, the chemotherapeutic commonly used as conditioning regiment before the HSCT, affected pathways regulating epithelial to mesenchymal transition, proliferation, and apoptosis in small intestinal organoids, as shown by transcriptomic and proteomic analysis. The co-culture of busulfan-treated intestinal organoids with MSCs reversed the effects of busulfan on the transcriptome and proteome of intestinal epithelium, which we also confirmed by functional evaluation of proliferation and apoptosis.ConclusionsCollectively, we demonstrate that our in vitro co-culture system is a new valuable tool to facilitate the investigation of the molecular mechanisms behind the therapeutic effects of MSCs on damaged intestinal epithelium. This could benefit further optimization of the use of MSCs in HSCT patients.

Fecal microbiota transplantation in capsules for the treatment of steroid refractory and steroid dependent acute graft vs. host disease: a pilot study.

Acute graft-versus-host disease (aGvHD) is a serious complication of allogeneic hematopoietic stem-cell transplantation with limited treatment options. The gut microbiome plays a critical role in aGvHD pathogenesis. Fecal microbiota transplantation (FMT) has emerged as a potential therapeutic approach to restore gut microbial diversity. In this prospective pilot study, 21 patients with steroid-resistant or steroid-dependent lower gastrointestinal aGvHD received FMT in capsule form. At 28 days after the first FMT, the overall response rate was 52.4%, with 23.8% complete and 28.6% partial responses. However, sustained responses were infrequent, with only one patient remaining aGvHD-free long-term. FMT was generally well-tolerated. Microbiome analysis revealed dysbiosis in pre-FMT patient stool samples, with distinct microbial characteristics compared to donors. Following FMT, there was an increase in beneficial Clostridiales and a decrease in pathogenic Enterobacteriales. These findings highlight the potential of FMT as a treatment option for steroid-resistant aGvHD. Trial registration number NCT #03214289.

Quality Control Analysis of Mesenchymal Stem/Stromal Cells During Investigational New Drug Application for GvHD Administration in China.

Graft-versus-host disease (GvHD), including the acute and chronic types (aGvHD, cGvHD), arise as the dominating secondary disease in patients with unsatisfying consequences of allogeneic hematopoietic stem cell transplantation (HSCT). Approximately half of GvHD patients were steroid-resistant, with a two-year overall survival rate lower than 20%. Worse still, there are no standardized criteria for an optimal second-line therapy for steroid-resistant aGVHD patients. Notably, pioneering investigators have highlighted the ameliorative or therapeutic effects of human umbilical cord-derived mesenchymal stem/stromal cells (hUC-MSCs) upon GvHD largely attributed to their unique hematopoietic-supporting and immunomodulatory properties. Of note, quality control (QC) is the prerequisite to assure the safety and quality of hUC-MSCs before investigational new drug (IND) applications and large-scale clinical applications. Herein, we summarize the state-of-the-art updates upon IND-associated QC and clinical trials of hUC-MSCs during allogeneic HSCT in China. Meanwhile, the supervisory policy and medical ethics of current licensed MSC products for GvHD administration and the concomitant opportunities and challenges have also been discussed.

Chronic GVHD after steroid-sensitive, -dependent, and -refractory acute GVHD: incidence and clinical outcomes.

Chronic graft-versus-host disease (cGVHD) is a major limitation to the long-term success of allogeneic hematopoietic cell transplantation (HCT). Our prior study of acute GVHD (aGVHD) defined distinct treatment-response groups based on the response to first-line corticosteroids: steroid-sensitive (SS), steroid-resistant (SR), and steroid-dependent (SD) aGVHDs. We conducted a retrospective, single-institution, cohort study to assess the incidence, risk factors, and clinical outcomes of patients with cGVHD after a previous diagnosis of SS, SD, or SR aGVHD, compared with those with no history of aGVHD. Among 784 consecutive adult and pediatric recipients of HCT for hematologic malignancies between 2008 and 2016, 347 (44%) developed aGVHD, with 13% SS, 12% SD, and 19% SR aGVHD. The 3-year cumulative incidence of cGVHD was 25%. Among those with cGVHD, 39% had no prior aGVHD diagnosis, whereas among those with a prior aGVHD diagnosis, 16% had SS, 24% had SD, and 21% had SR aGVHD. Mild or moderate cGVHD was highest among those with preceding SD aGVHD, whereas severe cGVHD was most frequent among those with previous SR aGVHD. We identified SD and SR aGVHDs as significant independent risk factors for the development of cGVHD after allogeneic HCT, whereas SS aGVHD was not a risk factor. Our study demonstrates that cGVHD after SD aGVHD did not have an intermediate prognosis between SR and SS groups as hypothesized; rather, cGVHD after both SD and SR aGVHD have similar prognoses. Our findings suggest that previous aGVHD response states are important predictors of cGVHD severity and outcomes.

Efficacy and Safety of MSCs Plus Basiliximab for the Treatment of Steroid-Resistant aGVHD after Haploidentical Stem Cell Transplantation: A Multicenter, Randomized, Open-Label Trial

Efficacy and Safety of MSCs Plus Basiliximab for the Treatment of Steroid-Resistant aGVHD after Haploidentical Stem Cell Transplantation: A Multicenter, Randomized, Open-Label Trial

Vedolizumab in highly resistant acute gastrointestinal graft-versus-host disease after allogeneic stem cell transplantation: A single-center pediatric series.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a lifesaving procedure in malignant and nonmalignant diseases. However, it is associated with a considerable risk of graft-versus-host disease (GvHD). Steroids are a first-line therapy for acute GvHD (aGvHD), but there is no standard treatment for steroid-resistant (SR) gastrointestinal (GI) aGvHD, which has a poor prognosis. The anti-integrin antibody, vedolizumab, could help in controlling SR GI aGvHD symptoms by blocking lymphocyte extravasation and infiltration of the intestinal wall. To report the outcomes of 3 children with SR GI aGvHD after allo-HSCT, treated with vedolizumab as the last chance drug. The study included 3 patients aged from 8 to 10 years who underwent HSCT in Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology at Wroclaw Medical University, Poland, and who developed severe SR GI aGvHD. All patients had grade IV SR aGvHD with GI stage 4 manifestation. Vedolizumab was given as salvage therapy after an ineffective treatment with etanercept, basiliximab, ruxolitinib, extracorporeal photopheresis, and mesenchymal stem cell infusions. Vedolizumab was administered intravenously at a dose of 300 mg. Only 1 patient achieved GvHD remission and was alive and well 9 months after the discontinuation of the therapy. One child developed a relapse of malignant disease and eventually died, and the third child died of severe aGvHD. Vedolizumab can be safely used in children with SR GI aGvHD, offering an additional chance for heavily pretreated patients. Prospective pediatric studies on both prophylactic and therapeutic use of the drug are warranted, according to the preliminary results.

Endoscopic Approach in the Diagnosis of Gastrointestinal Acute Graft Versus Host Disease in Children.

This was a retrospective study conducted, at the IRCSS Istituto G. Gaslini in Genova, Italy, in 26 children undergoing upper or lower GI endoscopy after allogeneic hematopoietic stem cell transplantation between 2000 and 2017. Histology confirmed a diagnosis of a-GvHD in 73% of patients; it was frequently associated with steroid-resistant a-GvHD (P = 0.001) and with an increased transplant-related mortality. Additionally, one patient developed duodenal hematoma after endoscopy for a high-grade GI a-GvHD. In our experience, the endoscopic approach in the diagnosis of GI a-GvHD in children was feasible and safe. Furthermore, the histological diagnosis of GI a-GvHD was associated with an increased risk of steroid-resistant GvHD and with high transplant-related mortality.

Steroid-resistant intestinal aGVHD and refractory CMV and EBV infections complicated by haplo-HSCT were successfully rescued by FMT and CTL infusion

Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) produces similar survival outcomes as HLA-matched sibling donor allogeneic HCST in younger patients with acquired severe aplastic anemia (SAA). This study reported a 29-years-old man with SAA and intracranial hemorrhage who underwent haplo-HSCT with a modified BU/CY + ATG conditioning regimen. Neutrophil and platelet engraftment were both achieved on day 14 after HSCT. The patient developed grade IV acute graft-versus-host disease (aGVHD) on day 20 and acquired cytomegalovirus (CMV) and Epstein–Barr virus (EBV) infections on day 47. After the failure of methylprednisolone, basiliximab, ruxolitinib, and antiviral treatment, the patient was diagnosed with steroid-resistant grade IV aGVHD and refractory CMV and EBV infections. We performed fecal microbiota transplantation and infused CMV- and EBV-specific cytotoxic T lymphocytes. After that the stool volume and frequency gradually decreased, and viral DNA was undetectable on day 80. This report provides helpful clinical experience for treating steroid-resistant aGVHD and refractory viral infections.

Mesenchymal Stromal Cells Plus Anti-CD25 Antibody and Calcineurin Inhibitors for Steroid-Resistant Acute Graft-Versus-Host Disease: A Multicenter, Randomized, Phase 3 Trial

INTRODUCTION Steroid-resistant (SR) acute graft-versus-host disease (aGVHD) lacks standard second-line treatment. Mesenchymal stromal cells (MSCs) have potential efficacy in SR aGVHD. To assess efficacy and safety of MSCs combined with anti-CD25 antibody and calcineurin inhibitors as second-line therapy for SR aGVHD.METHORDS A randomized phase 3 trial involved 203 SR aGVHD patients at 10 centers in China (September 2014-March 2019). Final follow-up was on June 30, 2020. Participants were randomized in a 1:1 ratio to receive second-line therapy (anti-CD25 antibody combined with calcineurin inhibitors) with MSCs (n=101) or without MSCs (n=102). The primary endpoint was overall response (OR) at day 28 with a predefined threshold of -20%. Secondary and safety endpoints included durable OR at day 56, failure-free survival, overall survival (OS), chronic GVHD (cGVHD), infection, haematological toxicity and relapse.RESULTS Of 203 patients, 198 (97.5%; mean age, 30.1years; 40.4% women) completed the study. OR at day 28 was higher in the MSCs group than in the control group (82.8% [82 patients] vs 70.7% [70]; odds ratio, 2.00; 95% confidence interval [CI], 1.01-3.94; P=.043). Durable OR at day 56 was also higher in the MSCs group (78.8% [78 patients] vs. 64.6% [64]; odds ratio, 2.02; 95% CI, 1.08-3.83; P=.027). The median failure-free survival was longer in the MSCs group compared with control group (11.3 months vs. 6.0 month; hazard ratio (HR) 0.68; 95% CI, 0.48-0.95, P=.024). The 2-year cumulative incidence of cGVHD was 39.5% (95% CI, 29.3%-49.4%) and 62.7% (51.4%-72.1%) in the MSCs and control groups (HR 0·55, 95% CI, 0·36-0·84; P=0·005). Within 180 days after study treatments, the most common grade 3 and 4 adverse events were infections (65 [65.7%] in the MSCs group vs 78 [78.8%] in the control group), haematological toxicity (37 [37.4%] vs 53 [53.5%]).CONCLLUSIONS MSCs plus second-line treatments may increase the efficacy of SR aGVHD, decrease drug toxicity of second-line therapy and cGVHD development, and are well tolerated. DisclosuresNo relevant conflicts of interest to declare.

Anti α4β7 Integrin Monoclonal Antibody (Vedolizumab) for the Treatment of Steroid-Resistant Severe Intestinal Acute Graft Versus Host Disease

Background: Steroid resistant (SR) acute Graft versus Host Disease (aGvHD) is a life-threating complication of allogeneic- stem cell transplantation (SCT); outcomes in grade III-IV are poor with mortality rates as high as 90%. Vedolizumab (Vd) is a monoclonal antibody inhibiting the binding of integrin α4β7 to Mad CAM -1, consequently impairing homing of T cells to the gastrointestinal (GI) endothelium. It is an approved therapy for inflammatory bowel disease (IBD). Encouraging results were recently reported by Floisand et al., in 6 patients (pts) with SR GI aGvHD (BBMT, 2017). We report a single center experience with the use of Vd in pts with severe SR GI GvHD.Methods: Medical records of 8 pts treated with Vd for SR GI aGvHD were reviewed. SR GI aGvHD was defined as progressive or refractory disease after receiving cyclosporine (CSA) and methylprednisolone (MP) at a dose of 2 mg/kg. Vd was administered at a dose of 300 mg IV, with planned repeated infusion after 2 and 6 weeks. Complete response (CR) was defined as complete resolution of GI aGvHD symptoms , including stopping of analgesics, total parenteral nutrition (TPN), and steroids. Partial response (PR) was defined as improvement in GI GvHD from grade III-IV to grade I-II.Results: Overall, 8 pts were included with a median age of 54 years (range, 21-66). AML was the leading diagnosis (50%). Graft source was peripheral blood in all patients. The majority of pts had HLA matched unrelated donor (5), followed by matched sibling donor (2), and a mismatched unrelated donor (1). Most pts received myeloablative conditioning regimens (6); GvHD prophylaxis included CSA (8) and Methotrexate (MTX) (6) or Mycophenolate Mofetil (MMF) (2). Anti Thyomoctye Globulin (ATG) was given to 7 pts.All pts were diagnosed with GI aGvHD according to clinical manifestations. Colonic biopsies, supporting the diagnosis, were performed in 4 pts. Liver and skin aGvHD was noted in 3 and 4 pts, respectively. Prior to Vd all patients had received IV MP 2mg/kg/day, CSA, oral non-absorbable steroids and MMF. TPN was given to 7 pts. Two patients had developed posterior reversible encephalopathy syndrome and were put off CSA (1 before and 1 after Vd).Five pts developed aGvHD at median of 30 days post SCT, 2 pts at 30 days post-donor lymphocyte infusion (DLI) and 1 pt at 9 months post SCT (30 days following CSA cessation). The majority of pts received only 2 of the 3 doses of Vd (5/8 pts). Two pts experienced multi-organ failure prior to Vd initiation, and died soon after the intervention. Six pts had a clinical GvHD response within a median of 10 days (range, 7-24 days) from Vd first administration. Two pts had CR and 4 PR of the GI aGvHD. Two CR pts were able to be taken off immunosuppression (Table). However, 3/6 pts succumbed to infection complications at median of 7.5 months (range, 2-10 months) post transplantation. Of the two patients in achieving CR of aGvHD, one developed severe neurologic dysfunction with features of Guillain-Barré syndrome and the other succumbed to AML relapse. Following Vd, 5 patients had a CMV reactivation, although 4 had experienced prior reactivations. No other viral infections (EBV, HHV6, HSV, JCV) were observed. Three pts had probable invasive aspergillosis infection and 7 patients had signs consistent with bacterial infections with or without bacteremia.Conclusions: Our data suggest that targeting integrin a4b7 can ameliorate severe SR GI aGvHD. Whether the high infection rates observed following administration are related to Vd or to prolonged immunosuppression is inconclusive. The timing, role and safety of Vedolizumab administration should be further explored in a clinical trial setting. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Steroid-dependent acute GVHD after allogeneic hematopoietic cell transplantation: risk factors and clinical outcomes

AbstractAcute graft-versus-host disease (aGVHD) has various risk factors and outcomes. We defined distinct aGVHD treatment response groups based on response to first-line corticosteroids: steroid sensitive (SS), steroid resistant (SR), and the rarely studied steroid dependent (SD) aGVHD. In 1143 consecutive adult and pediatric allogeneic hematopoietic cell transplant recipients, 385 (34%) developed aGVHD, with 10% having SS aGVHD, 9% SD aGVHD, and 14% SR aGVHD. The only factor significantly associated with SD in comparison with SS was older age (odds ratio [OR], 3.9; 95% confidence interval [CI], 1.4-11.3, when comparing 18- to 60-year-olds with <18-year-olds). Factors significantly associated with SR in comparison with SS were unrelated donor (OR, 3.0; 95% CI, 1.2-7.4) and Minnesota high-risk aGVHD (OR, 2.4; 95% CI, 1.3-4.6). SR aGVHD was independently associated with higher risk for 2-year overall mortality (hazards ratio [HR], 1.8; 95% CI, 1.2-2.8) and nonrelapse mortality (NRM; HR, 2.1; 95% CI, 1.2-3.9). SS and SD GVHD groups had similar overall survival and NRM. The cumulative incidence of chronic GVHD was highest in the SD group, followed by the SR and SS groups (46%, 41%, and 29%, respectively). SD and SS GVHD had similar prognoses, both markedly better than those of the SR groups.

Safety and Efficacy of Ruxolitinib in Steroid-Resistant Graft Versus Host Disease: A Systematic Review and Meta-Analysis

Introduction: Stem cell transplantation (SCT) is used to treat multiple malignancies, but a major complication of the procedure is graft versus host disease (GvHD), which is a significant cause of morbidity and death in SCT patients. Methylprednisolone is the first-line therapy of GvHD. Ruxolitinib is a Janus kinase (JAK) inhibitor that can dampen the effect of inflammatory cytokines involved in GvHD and may be used in patients refractory to steroid treatment. In this systematic review and meta-analysis, we assessed the safety and efficacy of Ruxolitinib in steroid-resistant (SR) acute (a) and chronic (c) GvHD. Methods: We performed a search on PubMed, Cochrane, Embase, and Web of Science. We used the keywords, "Ruxolitinib" AND "Graft vs Host Disease" from the inception of literature till 7/10/2020. We screened 694 articles and included 1 randomized clinical trial (RCT) (N=309), 4 non-randomized trials (NRCT) (N=232), and 13 observational studies (N=481) in this meta-analysis. We extracted data for efficacy (i-e, OS, CR, ORR) and safety (≥grade 3 treatment related adverse events (TRAE). We excluded case reports, case series, review articles, meta-analysis, and preclinical trials. We used the R programming language (version 4.0.2) to conduct a meta-analysis. Results: In the 18 included studies (N=1022), Ruxolitinib was used in patients with the age range of 6 months to 70 years. 417 participants had grade III-IV acute GvHD, and 272 participants had moderate to severe chronic GvHD (Table 1). In an RCT (N=309), patients aged between 12-73 years with SR aGVHD were randomized 1:1 to receive either Ruxolitinib or physician's choice drug. Overall response rate (ORR) and complete response (CR) were significantly higher in the Ruxolitinib group as compared to the physician's choice drug. The results were consistent for all grades of GvHD. Grade 3 or higher treatment-related adverse events (TRAEs) were 78% in the two groups. 22% of the patients died of GvHD related adverse events in the Ruxolitinib group vs. 25% of the patients in the control group. In 12 clinical trials and observational studies, among SR GvHD patients (N=443), pooled ORR was 0.74 (CI=0.65-0.81, I2=61%) with Ruxolitinib treatment. Similarly, pooled CR was 0.45 (CI=0.34-0.68, I2=81%). The most common adverse events were cytopenias, viral reactivation, and infections. (Fig 1, 2) In 9 early phase trials and observational studies (N=282) in SR- chronic GvHD patients, pooled ORR and pooled CR were 0.75 (CI=0.64-0.83, I2=64%) and 0.11 (CI=0.08-0.16, I2=0), respectively. The most common adverse events were cytopenias and viral reactivation (Fig 3, 4). In a non-randomized trial (N=64), Ruxolitinib was used in combination with Etanercept for SR- acute GvHD patients. The ORR and CR were 87.5% and 72%, respectively. High rates of hematological adverse events and infections were reported in these patients. In an observational study (N=18), Ruxolitinib was used in combination with Extracorporeal Photopheresis (ECP). The combination was well-tolerated, and ORR and CR were 55% and 44%, respectively (Table 1). Conclusion: Ruxolitinib was well tolerated by patients with acute or chronic SR-GvHD. Ruxolitinib showed a higher efficacy compared to the physician's choice drug in SR acute GvHD. Ruxolitinib was also effective in SR cGvHD patients. The addition of etanercept to Ruxolitinib increased the efficacy in SR-acute GvHD patients but resulted in an increased incidence of infections. Ruxolitinib with ECP was effective and well tolerated in SR-acute GvHD. Additional multicenter, randomized, double-blind clinical trials are needed to confirm these results. Disclosures Anwer: Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau.

Multipotent mesenchymal stromal cells application for acute graft versus host disease treatment

Analysis of the effectiveness of the MSCs aministration as the second- or third-line therapy of acute GVHD (aGVHD) resistant to glucocorticosteroid treatment. The study included 35 patients who received MSCs obtained from the bone marrow of healthy donors as a treatment of steroid-resistant aGVHD. The clinical parameters of patients, MSCs cultural characteristics, the MSC expression profile for various genes including those involved in immunomodulation, expression of cells surface markers, the source of MSCs, as well as the frequency and number of MSC administrations were analyzed. Response to therapy was achieved in 74% of cases, a complete response was reached in 13 (37%) patients, partial response/clinical improvement was demonstrated in 13 (37%). This treatment was ineffective in 9 patients. The prediction of a group of patients with good response to MSC therapy turned to be impossible. The differences between the effective and ineffective for the GVHD treatment MSCs samples were found. The effective ones were characterized with a decreased total MSCs production and an increase in the main histocompatibility complex and PDL-1 antigens expression. These data allow to select optimal samples for aGVHD treatment that can improve clinical results. aGVHD treatment with MSCs has shown efficacy comparable to other treatment approaches. Given the low percentage of complications and the absence of significant adverse effects, MSC therapy seems to be one of the optimal approaches to the treatment of resistant forms of GVHD.

Risk factors analysis for steroid-resistant acute graft versus host disease after haploidentical hematopoietic stem cell transplantation

目的分析单倍型造血干细胞移植（haplo-HSCT）后糖皮质激素耐药急性移植物抗宿主病（GVHD）的危险因素。方法回顾性分析2010年1月至2011年12月在北京大学血液病研究所接受haplo-HSCT后并发急性GVHD的成人急性髓系白血病/骨髓增生异常综合征患者的临床资料。结果共有85例急性GVHD患者纳入研究，男55例，女30例，中位年龄30（19~67）岁。糖皮质激素治疗后达到完全缓解（CR）53例（62.4%），部分缓解（PR）6例（7.1%），未缓解（NR）26例（30.6%）。Ⅰ/Ⅱ、Ⅲ/Ⅳ度急性GVHD组糖皮质激素治疗的CR率分别为66.2%（51/77）、25.0%（2/8）（χ2=3.639，P=0.048）；累及1个、2个靶器官急性GVHD组糖皮质激素治疗的CR率分别为77.4%（48/62）、21.7%（5/23）（χ2=22.157，P<0.001）；明尼苏达危险度积分标危、高危组糖皮质激素治疗的CR率分别为67.5%（52/77）、12.5%（1/8）（χ2=7.153，P=0.004）。单因素和多因素分析均显示明尼苏达危险度积分高危和移植物单个核细胞量≥8.33×108/kg是发生糖皮质激素耐药急性GVHD的独立危险因素。明尼苏达积分标危组（77例）、高危组（8例）移植后22个月总生存率分别为（90.3±3.8）%、（75.0±15.3）%（χ2=2.831，P=0.092）；糖皮质激素治疗CR组（53例）、非CR组（32例）移植后22个月总生存率分别为（95.2±3.4）%、（78.6±7.9）%（χ2=5.287，P=0.021）。结论明尼苏达危险度积分和移植物单个核细胞数可以预测haplo-HSCT后糖皮质激素耐药的急性GVHD。

Ann Arbor Score Predicts Thrombotic Microangiopathy but Not Graft-Versus-Host Disease in Pediatric Bone Marrow Transplant Recipients

Background The Mount Sinai Acute GVHD International Consortium (MAGIC) algorithm uses two biomarkers, ST2 and REG3α, measured on day 7 following allogenic stem cell transplant to predict aGVHD and 6-month NRM. This algorithm defines two risk groups denoted Ann Arbor high risk and low risk. The MAGIC algorithm has not been independently validated in the pediatric allogeneic stem cell transplant population. Transplant associated thrombotic microangiopathy (TA-TMA) is also associated with elevated ST2 levels and previous studies have shown TA-TMA is associated with steroid-resistant aGVHD. Incidence of TA-TMA was not evaluated in the previous adult studies using the 2-biomarker algorithm. Methods Biorepository blood samples were collected from 106 consecutive pediatric patients on day 7 following allogenic stem cell transplant between April 2014 and June 2017. ST2 and REG3α were measured via ELISA. The previously described 2-biomarker algorithm was performed on each patient to determine high-risk versus low-risk score for each patient. Outcomes examined included 6-month NRM, aGVHD and TA-TMA. Results Of the 106 patients, 18 patients were categorized as high risk and 88 low risk based on the 2-biomarker algorithm. Six-month NRM occurred in 5/18 high risk patients and 4/88 low risk patients (Fig. 1A). TA-TMA occurred in 7/18 high risk patients and 13/88 low risk patients (Fig. 1B). The 2-biomarker algorithm was not predictive of aGVHD with 5/18 high risk patients and 32/88 low risk patients having aGVHD (Fig 1C). There was no difference in mean REG3α levels in our patients with and without TA-TMA, aGVHD and 6-month NRM (Table 1). Interpretation The MAGIC algorithm does not predict aGVHD in our pediatric population, but rather TA-TMA and 6-month NRM. The algorithm is driven by ST2 levels as there was no significant difference in REG3α levels by outcome. Pediatric specific biomarker algorithms for prediction of aGVHD will need further delineated through future research. One potential explanation for this difference from adult studies is important differences in the population studied. Our population includes a high number of children with hemophagocytic lymphohistiocytosis leading to pre-existing endothelial injury.

Repeated Courses of Orally Administered Fecal Microbiota Transplantation for the Treatment of Steroid Resistant and Steroid Dependent Intestinal Acute Graft Vs. Host Disease: A Pilot Study (NCT 03214289)

Background: Steroid-resistant (SR) intestinal acute graft versus host disease (aGVHD) is a devastating complication of allogeneic hematopoietic stem cell transplantation. Preliminary reports suggest that fecal microbiota transplantation (FMT) administered through a nasogastric tube or colonoscopy may be an effective treatment. We report the results of a single-arm pilot study (NCT 03214289) using FMT in capsules to treat SR or steroid dependent (SD) intestinal aGVHD.Methods: The primary outcome was the occurrence of severe adverse events (SAEs) at 28 days post last FMT course. Secondary outcomes included GVHD response. Complete response (CR) was defined as resolution of gastrointestinal symptoms or reduction of steroid dose to 5 mg of prednisone. Partial response was defined as a decrease in severity of GVHD by at least one stage or a ≥40% reduction in steroid dose. Patients were eligible if they had SR or SD gut aGVHD without active infection or neutropenia. Per-protocol, participants received a course of 30 frozen capsules of fecal matter over two consecutive days. FMT courses could be repeated from the same or a different donor, at the treating physician's discretion. Capsules are produced from healthy unrelated donors who underwent vigorous screening. They are taken orally and are flavorless and odor-free. To characterize the impact of the FMT on the gut microbiota, stool samples of recipients were serially collected and underwent 16s rRNA sequencing.Results: To date, we have enrolled 7 patients with intestinal aGVHD (6 SR, 1 SD) (Table). The median dose of methylprednisolone (MP) was 1 mg/kg (interquartile range [IQR] 0.8-1.3 mg/kg). FMT was administered at a median of 39 days (IQR 21-58 days) from aGVHD diagnosis. A total of 15 courses of FMT were given. Patients received a range of 1-3 FMT courses (median 2). The capsules were well tolerated. Patient #1 developed Enterococcus Faecium bacteremia 2 days following the second FMT. To track the source of bacteremia, we performed targeted metagenomic sequencing. The enterococcus strain from the blood culture was identified in the recipient's pre-FMT stool sample but not in the FMT inoculum (i.e., capsule), confirming that the bacteremia was not an FMT complication. Similarly, patient #6 developed Pseudomonas aeruginosa bacteremia 3 days after the 2nd FMT. 16s rRNA sequencing of the donor capsule failed to demonstrate Pseudomonas taxa. No other SAEs suspected to be related to the FMT were observed. Two patients achieved a CR with complete resolution of GVHD symptoms. Patient #6 had a partial improvement following the 1st FMT, with a reduction of MP from 2 mg/kg to 1.3 mg/kg. Three days after the 2nd FMT, she developed fatal pseudomonas bacteremia, not related to the FMT as detailed above. At last follow-up (median 61 days, IQR 40-99), 3/7 patients were alive. Three patients died from consequences of active GVHD, while one patients who responded to FMT and was free of GVHD, succumbed to an invasive Aspergillus infection of the brain.16s rRNA sequencing of stool samples revealed bacterial domination (i.e., occupation of at least 40% of the microbiota by a single predominating taxon) of Escherichia(E) coli in four patients before FMT, with a major reduction following therapy. FMT was associated with the introduction of new bacteria and an increase in bacterial diversity in the recipient's stool (Figure).Conclusions: We demonstrate for the first time the utility of fecal microbiota transplantation in orally administered capsules for the treatment of severe intestinal acute GVHD. The capsules were well tolerated and safe. Metagenomic sequencing proved that a bacterial infection following FMT was not related to the procedure. Sequencing of the stool sample revealed bacterial domination with E.coli in 4/7 patients prior to the first FMT. Following FMT, bacterial diversity increased. Finally, 2/7 patients attained a complete response following therapy, suggesting a potential role of FMT in patient management.Figure. (A) Heatmap of operational taxonomics units (OTU). Each column marks a sequenced stool sample at a specific time point and rows individual taxas. The color code indicates relative abundance. Dotted lines represent an FMT course. Before FMT all patients, aside from patient #6, had markedly reduced diversity, with enrichment of OTUs following treatment. (B). Change of bacterial diversity, measured by the Shanon diversity index before and after FMTs. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Expandation of CD56-Bright NK Cell in Patients with Steroid-Refractory Graft-Versus-Host Disease Treated with Basiliximab and Etanercept

Objectives: Steroid-resistant aGVHD(SR-aGVHD) is a complication with high incidence of mortality following allogeneic stem cell transplantation. Our previous study has showed combined treatment by basiliximab and etanercept achieved high response in SR-aGVHD. The aim of this study is to investigate the changes of lymphocyte subsets in SR-aGVHD following treatment with basiliximab and etanercept.Methods: We treated 11 SR-aGVHD patients with basiliximab 20mg on days 1, 4, 8, 15, and etanercept 25 mg twice a week for 4 weeks, followed by once weekly for 4 more weeks. Their peripheral blood lymphocyte subsets were assessed by flow cytometry before and after treatment.Results: The overall response to treatment was 100% (11/11) with 72.7% (8/11) achieving a complete response. As expected, we found a significant depletion of both CD4+ and CD8+ T-cell subset at 4w following treatment. Conversely, the proportion of CD3-CD56+NK expanded significantly, accounting for 26.82±7.69% of PB lymphocytes at 6w following treatment, compared with 10.90±3.94% before treating. The increasement in NK proportion lasting from several weeks to several months. Moreover, the percentage of CD56bright and IFN-gamma-producing NK cell subsets also increased after combined treatments.Conclusion: Expansion of CD56(bright) and IFN-gamma production NK cell subsets and contraction of CD4(+) and CD8(+) T cell numbers may contribute to the well control of SRaGVHD by basiliximab and etanercept. This finding provides supporting evidence for NK cell-mediated negative immunoregulation of activated T cells during aGVHD. DisclosuresNo relevant conflicts of interest to declare.

Mesenchymal Stromal Cells for Treatment of Acute Steroid-Refractory Graft Versus Host Disease: Clinical Responses and Long-Term Outcome.

Acute graft-versus-host disease (aGvHD) remains a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Steroid-resistant aGvHD is associated with poor outcome, and no commonly accepted salvage therapy is available for its treatment. Here, we report 58 adult patients treated with mesenchymal stromal cells (MSCs) as salvage therapy for steroid-refractory aGvHD. Third-party MSCs expanded in platelet lysate-containing medium were transfused at a median dose of 0.99 × 10(6) cells per kg b.wt. A median of two MSC infusions were administered to each patient. Median time between the onset of aGvHD and the first infusion of MSCs was 12 days (range, 6-62 days). Most patients (79%) had grade IV aGvHD. Five patients showed complete response, five showed very good partial response, 17 showed partial response, and 31 showed no response. The estimated probability of survival after 1 year was 19%, and median survival was 69 days. Overall survival was not significantly different from that of a historical cohort of patients receiving alternative salvage therapy and no MSC infusions. In conclusion, MSC treatment on top of conventional immunosuppression was associated with an overall response rate of 47% but improved outcome in terms of survival remains to be shown.

Treatment of Acute Graft-versus-Host Disease in Childhood with Extracorporeal Photochemotherapy/Photopheresis: The Padova Experience

Acute graft-versus-host disease (aGVHD) is the major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Systemic steroid treatment represents the first-line therapy for aGVHD and is associated with a response rate of 30% to 60%. Steroid-resistant patients have a poor prognosis with high transplantation-related mortality (TRM). Several second-line therapies have been proposed for the management of unresponsive aGVHD, without proven beneficial effects on patients' outcome or overall long-term survival. For these reasons, extracorporeal photochemotherapy/photopheresis (ECP), a cell-based approach to control GVHD that spares generalized immunosuppression, seems to be promising. In this study, we report the outcome of 72 consecutive pediatric patients treated with ECP between 1997 and 2013 for aGVHD. Among them, 21 patients had steroid-resistant aGVHD, 42 had steroid-dependent aGVHD, and 9 did not receive steroid as first-line therapy because of clinical contraindications. A complete response was obtained in 72% of patients, a partial response was observed in 11%, and there was no response in 17% of patients. At day +180, TRM was 4% in the whole cohort; TRM was 3% and 20% among responders and nonresponders to ECP, respectively (P < .0001). The 5-year overall survival was 71%, showing a difference between responders and nonresponders of 78% and 30%, respectively (P = .0004). The 5-year time to progression of primary disease was 81%, without any significant difference between the 2 groups. Moreover, the 5-year progression-free survival of primary disease was 72%, with a significant difference (P = .0007) between responders (79%) and nonresponders (30%) to ECP. In conclusion, this study demonstrates that ECP is highly effective in aGVHD without a negative impact on primary disease.