Abstract
Abstract 2546
Alemtuzumab-containing reduced intensity transplantation regimens frequently induce a state of partial T cell chimerism in the blood of the recipient. It has been widely shown that partial T cell chimerism is associated with freedom from graft versus host disease (GVHD) and that the occurrence of GVHD is often associated with rapidly rising donor T cell engraftment. The mechanism by which this occurs remains unknown and recipient cells may be killed, out-competed for homeostatic niches or simply diluted out by expanding donor T cells. The skin, a target organ of GVHD, normally contains T cells which enter from the blood in the steady state. Studies in mice have highlighted the gate-keeping function of inflammation in allowing trafficking of host-reactive donor T cells into tissues during conversion from mixed to full donor chimerism in blood. This implies that the equilibration of donor engraftment in the blood and tissue may occur more rapidly in patients at risk for GVHD. To test this hypothesis, we set out to define the relationship between skin and blood donor T cell engraftment in patients with and without GVHD.
Methods:
We studied a group of 51 patients receiving fludarabine melphalan (FM) conditioning with alemtuzumab 30mg for matched related donors and 60mg for matched unrelated donors. Skin biopsies were obtained at 28 and 100 days post transplant, dermal T cells isolated by migration and chimerism assessed in sex-mismatched transplants by combined immunofluorescence/in situ hybidization for XY chromosomes. Peripheral blood myeloid (CD15+) and T cell (CD3+) chimerism was determined by short tandem repeat amplification at monthly intervals after transplantation. All patients gave consent for clinical follow up and post transplant blood and skin sampling for research purposes, according to protocols approved by the local research ethics committee of Northumberland and North Tyneside.
Results:
All patients achieved >95% myeloid engraftment by day 100. Median (range) T cell engraftment was variable and significantly higher after MUD transplants: 70% (9-99%) than MRD transplants: 21% (5-85%; Mann Witney p <0.05). The incidence of acute GVHD was also greater after MUD transplantation at 47% (grade I or II) compared with 11% (grade I only) for MRD recipients. Overall a positive correlation was observed between donor T cell engraftment in skin and blood at all time points (r = 0.5792; P 0.0187) and at 100 days (r = 0.6570; P 0.0281). Analysis of the data with respect to GVHD showed a further interesting finding. Patients who developed GVHD had the closest correlation between blood and skin donor engraftment, even when they were in a state of partial T cell chimerism prior to the onset of GVHD. Patients who did not develop GVHD but nonetheless eventually achieved full donor engraftment in the blood tended to show lower levels of donor T cell engraftment in the dermis at day 100. Individual examples of patients who did not develop GVHD are: blood 77%, dermis 37%; blood 77%, dermis 6%; blood 92%, dermis 25%, compared with patients who did develop GVHD: blood 55%, dermis 56%; blood 90%, dermis 75%; blood 100%, dermis 100%.
Conclusion:
This analysis supports the hypothesis that the equilibration of blood and tissue donor T cells is influenced by GVHD and may offer a means to predict patients at risk of GVHD after withdrawal of immunosuppression or donor lymphocyte infusion.
Disclosures:
No relevant conflicts of interest to declare.
Rapid donor T-cell engraftment increases the risk of chronic graft-versus-host disease following salvage allogeneic peripheral blood hematopoietic cell transplantation for bone marrow failure syndromes