Easix Is Strongly Associated with Complement Activation and Overall Survival in Adult Allogeneic Hematopoietic Cell Transplantation Recipients

Introduction: Endothelial dysfunction is a common denominator of graft-versus-host disease (GVHD) and transplant-associated thrombotic microangiopathy (TA-TMA). The latter is also characterized by excessive complement activation. Recent studies have introduced the Endothelial Activation and Stress Index (EASIX) as a potential predictor of survival in patients with GVHD. We hypothesized that EASIX would predict complement activation and survival in patients with GVHD and TA-TMA. Methods: We enrolled consecutive adult TA-TMA (International Working Group/IWG criteria), acute and/or chronic GVHD and control allogeneic hematopoietic cell transplantation (HCT) recipients in a 1:1:1 ratio (January 2015-December 2018). Plasma was collected and stored immediately at -80oC at the first day of confirmed TA-TMA or GVHD diagnosis and at a similar post-transplant period in control recipients. EASIX [lactate dehydrogenase (U/L) × creatinine (mg/dL)/thrombocytes (10⁹ cells per L)] was calculated at day 0, 30, 100 and last follow-up. Complement activation was detected measuring soluble C5b-9/membrane attack complex (ELISA, Quidel). Results: We studied 20 TA-TMA, 20 GVHD and 20 control patients (Table 1). TA-TMA developed at a median of 125 post-transplant day (range 9-2931); whereas the first day of confirmed GVHD diagnosis was at a median of 78 post-transplant day (range 16-145). EASIX at day 100 and last follow-up differed significantly among groups (p=0.014 and p=0.001, Table 1), although there was no significant difference between TA-TMA and GVHD patients. In contrast, soluble C5b-9 was significantly higher in TA-TMA compared to GVHD (p=0.008) and control patients (p<0.001, Bonferroni's correction). Soluble C5b-9 levels were strongly associated with EASIX at day 100 and last follow-up (r=0.318, p=0.018 and r=0.321, p=0.020). Among laboratory values used to calculate EASIX (LDH, creatinine, platelets), C5b-9 was associated only with creatinine levels at day 100 (r=0.316, p=0.023), suggesting that the association between EASIX and C5b-9 is not driven by laboratory values per se. Furthermore, EASIX at day 0 and last follow-up was significantly associated with overall survival (p=0.013 and p=0.046). Among other pre-transplant factors studied (age, disease type and phase at transplant, donor), EASIX at day 0 was an independent predictor of overall survival (beta=2.627, p=0.029). Conclusion: Our study shows for the first time that EASIX predicts complement activation and overall survival in patients with endothelial dysfunction syndromes and control HCT recipients. Our findings suggest that EASIX may be a useful dynamic marker reflecting the course of endothelial dysfunction in these patients. Disclosures No relevant conflicts of interest to declare.

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The Impact of Colonization with Multidrug-Resistant Bacterial Pathogens (MRP) in Allogeneic Hematopoietic Cell Transplantation - Clearance of the MRP Is Pivotal for Survival

Blood ◽

10.1182/blood.v128.22.3421.3421 ◽

2016 ◽

Vol 128 (22) ◽

pp. 3421-3421

Author(s):

Daniela Heidenreich ◽

Sebastian Kreil ◽

Klaus-Peter Becker ◽

Thomas Miethke ◽

Wolf-Karsten Hofmann ◽

...

Keyword(s):

Overall Survival ◽

Cell Transplantation ◽

Hematopoietic Cell Transplantation ◽

Bacterial Pathogens ◽

Enterobacter Cloacae ◽

Multidrug Resistant ◽

Hematopoietic Cell ◽

Allogeneic Hematopoietic Cell Transplantation ◽

Klebsiella Pneumonia

Abstract Multidrug-resistant bacterial pathogens (MRP) such as extended-spectrum beta-lactamase producing enterobacteriaceae (ESBL), vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and multi-resistant Pseudomonas aeruginosa (P. aeruginosa) are an emerging challenge in allogeneic hematopoietic cell transplantation (HCT). However, no comprehensive data are available on the prevalence of MRP, their impact on the outcome after HCT and on the probability to clear a MRP. It was the purpose of this study to systematically analyze the issue of MRP in HCT. PATIENTS AND METHODS: From 07/2010 to 12/2015 a total number of 121 (43 F; 78 M) consecutive patients who received the first allogeneic HCT at our institution were analyzed retrospectively. As baseline investigation before conditioning all patients underwent a comprehensive screening for MRP. Swabs from nose, throat, axilla, urethra and anus as well as samples from stool and urine were collected. During the course of transplantation surveillance cultures were performed weekly. In addition, routine microbiological investigations were done from blood, urine, swabs, stool or central venous catheters whenever clinically needed. In MRP colonized patients surveillance stool specimen were taken until the MRP was repeatedly non-detectable. Multidrug-resistant gram neg. bacteria were categorized as 4MRGN (resistant to cephalosporins, piperacillin, fluorochinolones and carbapenems) or as 3MRGN (resistant to 3 of these 4 antimicrobial drug groups). The primary endpoint of this analysis was day 100 non relapse mortality (NRM). Secondary endpoints were NRM and overall survival (OS) after 2 years. A further endpoint in MRP+ patients was the time to non-detectability of the MRP. RESULTS: The patient characteristics were as follows: Underlying diseases were AML (62), ALL (7), CML (8), MPN (5), lymphoma (9), MDS (25), and multiple myeloma (5). The conditioning regimen was myeloablative in 50, reduced intensity in 71 patients. Patients were transplanted with peripheral blood stem cells (105) or bone marrow (16) from matched siblings (28), matched unrelated (67), mismatched (15) or haploidentical donors (11). 33 patients (27%) were colonized by at least one MRP (MRP+ group) either at baseline (baseline MRP+ group, n=18, 15%) or at any other time point until day 100 post HCT. The 33 MRP+ group patients were colonized by 42 MRP (baseline MRP+ group: 19 MRP). Detected MRP were 3MRGN E. coli or Klebsiella pneumonia (17), 4MRGN (9) or 3MRGN (2) P. aeruginosa, multi-resistant Stenotrophomonas maltophilia (2), 3MRGN Citrobacter freundii (1), 3MRGN Acinetobacter baumanii (1), 4MRGN Enterobacter cloacae (2), VRE (7) and MRSA (1). Out of these 33 patients 12 (36%) developed an infection with an MRP after HCT: septicemia (n=9), pneumonia caused either by 3MRGN Klebsiella (n=1) or by 4MRGN P. aeruginosa (n=1) and urinary tract infection by 4MRGN Enterobacter cloacae (n=1). 5 patients died MRP related due to septicemia (4MRGN P. aeruginosa n=4, VRE n=1). However, day 100 and 2-year NRM of MRP colonized vs non-colonized patients were essentially the same: 15 and 21% vs 15 and 24%, respectively. Even for the baseline MRP+ group there was no significant difference of NRM: 17 and 29% vs 15 and 22%. Overall survival was also not impaired in the MRP+ group 2 years post HCT (median follow up 32.4 months, range 7.5 to 71.4 months): MRP colonized versus non-colonized patients: 60 vs 55% (baseline MRP+ group 54 vs 58%). Out of the 33 MRP+ group patients 21 patients were able to clear the MRP. On day 100 after HCT 36% of patients had been able to clear the MRP. Median time to non-detectability of the MRP was 6.3 months. In 12 patients the MRP did not disappear until the end of the observation period or death (median follow up 15 months). There was a highly significant (p<0.0001) survival difference between patients who cleared the MRP vs those with MRP persistence. Whereas 17 out of 21 (81%) patients who cleared the MRP survived, only 2 out of 12 patients with MRP persistence stayed alive (median survival 6.6 months). Day 100 NRM was 4 vs 42% (p=0.0023). CONCLUSIONS: Since colonization by MRP had no neg. impact on the outcome in our cohort HCT of MRP colonized patients is feasible. However, the outcome of patients who do not clear their MRP is dismal. In order to increase the probability to clear the MRP we suggest to review the use of antibiotics in MRP colonized patients critically. Disclosures No relevant conflicts of interest to declare.

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Validation of Different Prognostic Scores in Allogeneic Hematopoietic Cell Transplantation in the Post-Transplant Cyclophosphamide Era

Blood ◽

10.1182/blood-2021-153069 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 3925-3925

Author(s):

Maria Queralt Salas ◽

Luis Gerardo Rodríguez-Lobato ◽

María Suárez-Lledó ◽

Nuria Martínez-Cibrian ◽

Teresa Solano ◽

...

Keyword(s):

Cell Transplantation ◽

Research Funding ◽

Operating Characteristic ◽

Hematopoietic Cell Transplantation ◽

Hematopoietic Cell ◽

Prognostic Scores ◽

Predictive Capacity ◽

Post Transplant ◽

Gvhd Prophylaxis

Abstract INTRODUCTION The use of post-transplantation cyclophosphamide (PTCy) for graft-versus-host disease (GvHD) prophylaxis has decreased the rates of this complication, resulting on an improvement of transplant-related toxicity and survival. Secondary to its efficacy, the use of PTCy has been almost universally integrated for allogeneic hematopoietic cell transplantation (alloHCT), independently of the selected donor source. Clinical decisions in alloHCT are supported by the use of prognostic scores for outcome prediction. However, capability of prediction by diverse scores can vary depending on their features and on the composition of the study cohort. Additionally, the continuous innovation on alloHCT techniques and practices leads to an ongoing need to update risk indices aimed at improving risk stratification of patients undergoing alloHCT. This study explores the predictive capacity of different prognostic scores routinely used in alloHCT, in a contemporaneous cohort of adults undergoing peripheral blood (PB) alloHCT using PTCy-based GvHD prophylaxis. METHODS Between 2014 and 2020, 230 consecutive adults with hematological malignancies underwent PB-alloHCT with PTCy-based GvHD prophylaxis at our Institution. Data related to Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI), Karnosfky Performance Status (KPS), Disease Risk Index (DRI), European Bone Marrow Transplantation (EBMT) score, and Endothelial Activation and Stress Index (EASIX) were collected retrospectively. Complete information was available for 216 patients. Overall survival (OS) was considered the main outcome variable. Patients were grouped into two risk groups based on the optimal cut-off value for each score. In the case of EASIX, 1.578 was the most discriminating cut-off for OS. The score discrimination for OS was measured independently for each index using the receiver operating characteristic curve (AUC) calculated using receiver operating characteristic (ROC) curves, and determined at different time-points after alloHCT. RESULTS Of the 216 patients included, the median age was 52 years (range: 18-70), acute myeloid leukemia (36.1%) was the most prevalent baseline diagnosis, 42.1% of adults underwent reduced-intensity conditioning alloHCT, 69.4% received grafts from unrelated donors, and 23.0% from haploidentical donors. With a median follow-up of 22.6 months, 24.1% patients relapsed, and 2-y OS and non-relapse mortality were 67.3% and 19.9%. DRI, HCT-CI, KPS, and EASIX successfully grouped patients into higher and lower risk strata, supporting their use for risk classification. HCT-CI [(score>3 (vs 0-3): HR 2.02, p<0.01], DRI [High - Very High risk (vs Low - Int): HR 2.08, p<0.01], and EASIX [>1.578 (vs ≤ 1.578): HR 1.73, p<0.02], maintained an optimal discrimination capacity during the entire post-transplant follow-up (median AUC ranges > 55%). DRI was the most accurate prognostic index during the entire post-transplant period (median AUC ranges > 60%). KPS score was found to be a useful predictor of mortality up to the first year after alloHCT and with the highest prognostic accuracy at 3 months (AUC 67.09%). HCT-CI score was found to present a better discrimination capacity once elapsed 6 months after alloHCT and with a peak of prediction capacity at 2 years (AUC 60.3%). EASIX, when measured at the pre-transplant evaluation, demonstrated to have acceptable predictive ability during the entire post-transplant period (median AUC > 55%), and with a peak of prediction at 3 months (AUC 62.6%). The EBMT score had the lowest predictive capacity in our analysis (Figure 1). CONCLUSION: This study validates, for the first time, the risk stratification capacity for OS of DRI, HCT-CI, KPS, and EASIX in PB-alloHCT with PCTy-based prophylaxis. Interestingly, the prediction accuracy of the prognostic scores differed depending on the time-period. This result can be taken into consideration to enhance the applicability of these scores and refine the clinical decisions taken based on the information provided from their use in routine clinical practice. Figure 1 Figure 1. Disclosures Lozano: Terumo BCT: Honoraria, Research Funding; Macopharma: Research Funding; Grifols: Honoraria. Rosinol: Janssen, Celgene, Amgen and Takeda: Honoraria. Esteve: Novartis: Consultancy, Research Funding; Astellas: Consultancy; Jazz: Consultancy; Pfizer: Consultancy; Novartis: Research Funding; Abbvie: Consultancy; Bristol Myers Squibb/Celgene: Consultancy.

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Impact of LEAM and CBV conditioning on gastrointestinal toxicity at early periods following hematopoietic cell transplantation: A retrospective study

JBMTCT ◽

10.46765/2675-374x.2021v2n2p51 ◽

2021 ◽

Vol 2 (2) ◽

pp. p51

Author(s):

Cristina De Paula Novaes

Keyword(s):

Overall Survival ◽

Digestive Tract ◽

Cell Transplantation ◽

Oral Mucositis ◽

Medical Records ◽

Hematopoietic Cell Transplantation ◽

Gastrointestinal Toxicity ◽

Hematopoietic Cell ◽

Gastrointestinal Mucositis

Objectives: To compare the severity of oral mucositis and the frequency of gastrointestinal mucositis, and to observe if there is impact of these adverse effects on overall survival (OS), in patients who underwent CBV (carmustine, BCNU, and VP-16) and LEAM (lomustine, etoposide, Ara-C, and melphalan) conditioning for autologous hematopoietic cell transplantation (aHCT). Method: We collected retrospective data from medical records (n = 120) of transplantation and mucositis in the digestive tract of Hodgkin’s and non-Hodgkin’s lymphoma patients. Results: The frequency of OM grade 1 was higher in LEAM (36.76%) than in CBV (19.72%, p=0.038). There were no significant differences between the frequency of gastrointestinal mucositis in the two regimens (CBV - 52.11% and LEAM - 63.27%, p=0.305). CBV regimen exhibited lower 1-year overall survival (OS) than did LEAM (p=0.003). Oral mucositis grade ≥2 was associated with reduced OS in the CBV group (p=0.013). CBV regimen (HR=2.98, p 0.005) and oral mucositis grade ≥2 (HR=2.17, p=0.013) interfered negatively on the OS rate. Conclusion: Oral mucositis was more severe in CBV than in LEAM, decreasing the OS rate. Further studies with comprehensive follow-up and toxicity analyses must be undertaken to clarify the safety of LEAM conditioning in the digestive tract.

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Residual Disease Detection by Flow Cytometry Predicts Risk of Relapse and Overall Survival in Patients with Acute Myeloid Leukemia Following Reduced Intensity- and Myeloablative- Allogeneic Hematopoietic Cell Transplantation

Blood ◽

10.1182/blood.v120.21.4098.4098 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4098-4098

Author(s):

Charlotte Ann Bradbury ◽

Janice Ward ◽

Paresh Vyas ◽

Nigel H. Russell ◽

Grimwade David ◽

...

Keyword(s):

Flow Cytometry ◽

Overall Survival ◽

Cell Transplantation ◽

Disease Burden ◽

Hematopoietic Cell Transplantation ◽

Residual Disease ◽

Hematopoietic Cell ◽

Post Transplant ◽

Reduced Intensity ◽

Acute Myeloid

Abstract Abstract 4098 Relapse after allogeneic hematopoietic cell transplantation (HCT) is usually incurable for acute myeloid leukemic (AML) patients. Residual disease (MRD) monitoring pre- and post-HCT may improve relapse prediction, allowing the targeted implementation of post-HCT interventions to at risk patients when disease burden is sufficiently low for these to be effective. Previous studies have shown that MRD detection by multiparameter flow cytometry (MRD MFC) at either pre- (Leung et al 2012, Walter et al 2011) or post- transplant (Yan et al 2012) timepoints is prognostic for myeloablative HCT outcome in AML. Quantification of hematopoietic populations enriched for leukemic stem cells such as CD34+CD38low or lymphoid-primed multi-potential progenitor-like (LMPP-like) (Lin-CD34+CD38lowCD90-CD45RA+) (Goardon et al 2011) may improve the specificity of MFC MRD assays. In this study we retrospectively evaluated the predictive value of MRD MFC at both pre- and post- HCT timepoints in a cohort of unselected AML/high risk myelodysplasia (MDS) patients (n=44) who underwent reduced intensity conditioning (RI n= 32, median age 59, range 34–70) or myeloablative (MA n=12, median age 28, range 19–47) HCT between June 2010 and November 2011 (Table 1). MFC MRD was assessed both by detection of standard leukemic- aberrant-immunophenotypes (LAIPs) (identified at presentation and/or relapse) and quantification of CD34+CD38low and LMPP-like progenitors (LSC-enriched progenitors, LSC-EP). Pre HCT, 37 patients (MA = 11, RI = 26) were assessable for MFC MRD. 15 (41%) were MRD positive (LAIP MRD+) and 47% (7/15) (MA = 37.5%, 3/8; RI = 57%, 4/7) of these relapsed post HCT compared to 8% (MA = 0%, RI = 9%) of MRD negative patients (LAIP-MRD-), (Fig 1 p 0.03). Post HCT, 34 patients (MA = 9, RI =25) were assessable for MFC MRD. 10 (37%) had detectable LAIP MRD positivity between 2 and 9 months post HCT. 80% of these relapsed (MA = 60%; RI = 100%) with a median disease free survival (DFS) post HCT of 5 months (MA = 4 months; RI = 5 months); there were no relapses in the 17 patients who remained LAIP MRD- at a median follow-up of 20 months (range 9–26). (p=0.0006, Figure 2a). Presence of MRD post-transplant was associated with significantly poorer overall survival (p=0.005). Although 1 patient with high MRD (in CR, LAIP >1%, LSC-EP +) pre HCT relapsed <3 months post HCT, in 8 of 9 other relapses MRD positivity detected at ≥ 2 months post HCT preceded clinical relapse by >1 month (median time to relapse from MRD detection of 1.5 months, range 1–6; OS, median 4 months, range 1 - not reached). CD34+CD38low progenitors (34+38low) were < 0.03% of bone marrow nucleated cells in the majority of patients. Detectable 34+38low were mainly CD45RA+ so in most cases correlated with LMPP-like quantitation. Pre HCT, 34+38low were detectable in 40% of patients who went on to relapse and in only 9% of those who have not yet relapsed. Post HCT, 34+38lowpositivity preceded frank relapse by ≥1 month in 60% of patients who relapsed. Only 6% of patients who have not yet relapsed had detectable 34+38low. LSC-LEP positivity appears prognostic for DFS and OS (Figure 2b) but for a lower frequency of relapses compared to LAIP MRD positivity (60% v 80%). Conclusions: These data suggest that post HCT MFC detection of LAIP MRD is predictive of relapse in RI as well as MA HCT. LSC-LEP quantitation may be prognostic in a subset of patients. Pre HCT MRD might be more predictive of relapse in RI than MA HCT. However, post HCT MRD positivity precedes most clinical relapses by a time window which may be sufficient for interventions such as azacytidine or donor lymphocyte infusion (DLI) when disease burden is still low. These results provide a basis for the use of MFC residual disease detection pre and post HCT to inform treatment decisions in reduced intensity as well as myeloablative HCT. Disclosures: No relevant conflicts of interest to declare.

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Long-term effect of hematopoietic cell transplantation on systemic inflammation in patients with mucopolysaccharidoses

Blood Advances ◽

10.1182/bloodadvances.2020003824 ◽

2021 ◽

Vol 5 (16) ◽

pp. 3092-3101

Author(s):

Brigitte T.A. van den Broek ◽

Caroline A. Lindemans ◽

Jaap Jan Boelens ◽

Eveline M. Delemarre ◽

Julia Drylewicz ◽

...

Keyword(s):

Cell Transplantation ◽

Systemic Inflammation ◽

Hematopoietic Cell Transplantation ◽

Hematopoietic Cell ◽

Type I ◽

Bone Homeostasis ◽

Control Subjects ◽

And Control ◽

Mps I

Abstract Mucopolysaccharidoses (MPS) are devastating inherited diseases treated with hematopoietic cell transplantation (HCT). However, disease progression, especially skeletal, still occurs in all patients. Secondary inflammation has been hypothesized to be a cause. To investigate whether systemic inflammation is present in untreated patients and to evaluate the effect of HCT on systemic inflammation, dried blood spots (n = 66) of patients with MPS (n = 33) treated with HCT between 2003 and 2019 were included. Time points consisted of pre-HCT and, for patients with MPS type I (MPS I), also at 1, 3, and 10 years of follow-up. Ninety-two markers of the OLINK inflammation panel were measured and compared with those of age-matched control subjects (n = 31) by using principal component analysis and Wilcoxon rank sum tests with correction. Median age at transplantation was 1.3 years (range, 0.2-4.8 years), and median time of pre-HCT sample to transplantation was 0.1 year. Normal leukocyte enzyme activity levels were achieved in 93% of patients post-HCT. Pretransplant samples showed clear separation of patients and control subjects. Markers that differentiated pre-HCT between control subjects and patients were mainly pro-inflammatory (50%) or related to bone homeostasis and extracellular matrix degradation (33%). After 10 years’ follow-up, only 5 markers (receptor activator of nuclear factor kappa-Β ligand, osteoprotegerin, axis inhibition protein 1 [AXIN1], stem cell factor, and Fms-related tyrosine kinase 3 ligand) remained significantly increased, with a large fold change difference between patients with MPS I and control subjects. In conclusion, systemic inflammation is present in untreated MPS patients and is reduced upon treatment with HCT. Markers related to bone homeostasis remain elevated up to 10 years after HCT and possibly reflect the ongoing skeletal disease, making them potential biomarkers for the evaluation of new therapies.

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Faculty Opinions recommendation of Haploidentical Hematopoietic Cell Transplantation with Post-Transplant Cyclophosphamide in a Patient with Chronic Granulomatous Disease and Active Infection: A First Report.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725844640.793535140 ◽

2017 ◽

Author(s):

Andrew Gennery

Keyword(s):

Chronic Granulomatous Disease ◽

Cell Transplantation ◽

Hematopoietic Cell Transplantation ◽

Hematopoietic Cell ◽

Granulomatous Disease ◽

Active Infection ◽

First Report ◽

Post Transplant ◽

Haploidentical Hematopoietic Cell Transplantation

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Abstract 135: Endothelial Dysfunction in Acute Graft-versus-host Disease After Allogeneic Hematopoietic Cell Transplantation. In vitro Evidence of the Protective Effect of Defibrotide

Arteriosclerosis Thrombosis and Vascular Biology ◽

10.1161/atvb.36.suppl_1.135 ◽

2016 ◽

Vol 36 (suppl_1) ◽

Author(s):

Enrique Mir ◽

Marta Palomo ◽

Enric Carreras ◽

Maribel Diaz-Ricart ◽

Montse Rovira ◽

...

Keyword(s):

Endothelial Dysfunction ◽

Protective Effect ◽

Cell Transplantation ◽

Graft Versus Host Disease ◽

Hematopoietic Cell Transplantation ◽

Endothelial Damage ◽

Hematopoietic Cell ◽

Graft Versus Host ◽

Acute Graft

Acute Graft-Versus-Host Disease (aGVHD) is the most common early complication after allogeneic Hematopoietic Cell Transplantation (allo-HCT). We demonstrated endothelial dysfunction (ED) in association with allo-HCT. According to this data, aGVHD has been linked to an inflammatory process that may affect the endothelium. To investigate the differential degree of endothelial damage in patients developing or not aGVHD, to identify potential biomarkers, and to explore the protective effect of defibrotide (DF) in this scenario. DF has orphan designation for GVHD prevention. Patients blood samples were collected before allo-HCT, at day 0, and every week till day 28 after HCT. Plasma proteins (sTNFR1, sVCAM-1, VWF and ADAMTS-13) were measured as biomarkers of ED in individual samples from patients developing (GVHD, n=24), or not (NoGVHD, n=13), aGVHD. In in vitro assays, endothelial cells (EC) in culture were exposed to media containing pooled sera from patients to evaluate changes in the: a) expression of VCAM-1 and ICAM-1 on cell surfaces; b) presence of VWF on the extracellular matrix (ECM) and c) reactivity of the ECM towards platelets, under flow. The effect of DF was explored in the in vitro experiments by previous exposure of the EC (for 24h) followed by continuous incubation (100 μg/ml, added every 24h). Levels of sTNFRI, sVCAM-1 and VWF in samples from group GVHD were significantly higher than in NoGVHD (increases of 100, 37 and 150% respectively, at diagnose, p<0.01). ADAMTS-13 activity and VWF levels were inversely related. In in vitro studies, cell surface expression of VCAM-1 and ICAM-1, presence of VWF and platelet adhesion on the ECM in response to GVHD samples were always superior (increases vs NoGVHD of 80, 40, 100 and 21%, respectively, at diagnose). In vitro exposure of EC to DF attenuated signs of endothelial injury reducing significantly (p<0.05) the expression of VCAM-1, ICAM-1 and VWF (reductions of 22, 30 and 30%, respectively) in the GVHD condition. Our results demonstrate endothelial damage in association with aGVHD, as evidenced by elevated plasma levels of several biomarkers. The in vitro approach showed a marked proinflammatory and prothrombotic phenotype in association with aGVHD, which could be significantly prevented by defibrotide.

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