scholarly journals Fecal Microbiota Transplantation As a Therapeutic Option for Graft-Versus-Host-Disease: A Systematic Review and Future Directions

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4869-4869
Author(s):  
Hafiz muhammad Aslam ◽  
Sindhusha Veeraballi ◽  
Shahrukh K. Hashmi
Keyword(s):  
Graft Versus Host Disease ◽  
Clinical Studies ◽  
Case Reports ◽  
Therapeutic Option ◽  
Systemic Review ◽  
Fecal Matter ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host

Abstract Introduction: In recent years, there has been an expanding focus on interplay between intestinal microbiotal diversity and outcome of acute graft versus host disease(GVHD) in hematopoietic stem cell transplantation (HCT) recipients. One of the compelling intervention to maintain healthy gut microbiota for better outcome of GVHD in HCT recipients is Fecal microbial transplantation(FMT). Several non randomized small clinical studies and case reports on the efficacy and safety of FMT were reported so far. However, the ultimate role of FMT as a therapeutic option to treat GVHD is yet to be determined due to lack of randomised, large scale, statistically significant studies. Here in, we report a systemic review of literature available so far in an effort to establish a definite role of FMT. Methodology: A systemic literature search was conducted using various electronic databases. The case reports, case series and clinical studies related to FMT were used as a therapeutic or preventative modality specifically for GVHD are included. Results: Upon pooling of data, 87 patients from 6 studies and 5 case reports were included in the study in which complete remission(CR) occured in 43.7% and partial remission(PR) occured in 20.7% patients which is equivalent to 64.4% overall response rate in treating GVHD. Furthermore, out of all the species in fecal matter, clostridium was found to be the most valuable species in decreasing the rates of GVHD re-occurrence. Only a limited number of patients had treatment-related mortality (TRM) from GVHD while few showed mild GI-related (abdominal pain/distention, nausea, regurgitation) and non-GI adverse reactions including infections, anemia, thrombocytopenia, paroxysmal, and atrial fibrillation. We emphasize that the most of the patients did not have any major complications after FMT. Conclusion: We conclude that the FMT is a safe and effective strategy for the management of GVHD based on our study. The establishment of gut diversity along with the patient's intrinsic factors like fucosyltransferase 2 (FUT2) secretor status and baseline gut microbial diversity play a major role in the success of FMT. Given the restricted size and absence of randomized data, one cannot portray FMT as a standard of care yet, however, the low or absent toxicity along with improvement in survival justifies this modality to be tested in a randomized fashion. We strongly encourage the transplant community to enroll patients in innovative trials utilizing FMT, as this may be a one of the safest strategies for both prevention and treatment of GVHD Disclosures No relevant conflicts of interest to declare.

scholarly journals Ruxolutinib in Steroid Refractory Graft Versus Host Disease (SR-GVHD): Systemic Literature Review

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 5682-5682
Author(s):  
Mostafa F. Mohammed Saleh ◽  
Shahrukh K. Hashmi
Keyword(s):  
Adverse Events ◽  
Graft Versus Host Disease ◽  
Chronic Gvhd ◽  
Infectious Complications ◽  
Systemic Review ◽  
Close Monitoring ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Steroid Refractory

Background: Graft versus host disease (GVHD) is a main cause of morbidity and mortality in patients having undergone allogeneic hematopoietic stem cell transplantation (HSCT). About 30-40% of patients have steroid‐refractory GVHD (SR‐GVHD) after the first‐line use of high doses of corticosteroids with a poor prognosis .Ruxolitinib is a promising treatment for SR-GVHD. However, data regarding optimum dosing, response rates and associated adverse events are scarce. Herein, we provide the first systemic review of literature for the use ruxolutinib in GVHD. Methods: A Medline (PubMed), google scholar, OVID and Cochrane Database of Systematic Reviews search using key words "Ruxolutinib and GVHD", "Ruxolutinib and SR-GVHD" was undertaken in June 2019. Only peer reviewed databases were searched and search was restricted to human studies of acute and chronic GVHD only. Results: 16 publications, as listed in Table 1. Only one was a prospective trial, all others were retrospective studies, case series (5), and case reports (2). Overall response, ranged 45% - 100%, complete response was noted in 5.2% -80% patients. Time to response was variable from 1-12 weeks. Cytopenias and infectious complications were frequently reported with dose reduction or interruptions needed in most studies. Maintained responses were reported in a small proportion after ruxolutinib discontinuation. Conclusion Ruxolutinib has promising efficacy in SR-GVHD , however cytopenias and infectious complications reported frequently mandate close monitoring. Results of ongoing prospective trials could provide answers for optimum dosing and response assessment, and management of related adverse events. Table Disclosures No relevant conflicts of interest to declare.

scholarly journals The Role of Intestinal Microbiota in Acute Graft-versus-Host Disease

2015 ◽  
Vol 2015 ◽  
pp. 1-9 ◽  
Author(s):  
Yuanyuan Chen ◽  
Ye Zhao ◽  
Qiao Cheng ◽  
Depei Wu ◽  
Haiyan Liu
Keyword(s):  
Immune Responses ◽  
Intestinal Microbiota ◽  
Graft Versus Host Disease ◽  
Inflammatory Diseases ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Host Immune Responses ◽  
Acute Graft

The mammalian intestinal microbiota is a complex ecosystem that plays an important role in host immune responses. Recent studies have demonstrated that alterations in intestinal microbiota composition are linked to multiple inflammatory diseases in humans, including acute graft-versus-host disease (aGVHD). aGVHD is one of the major obstacles in allogeneic hematopoietic stem cell transplantation (allo-HSCT), characterized by tissue damage in the gastrointestinal (GI) tract, liver, lung, and skin. Here, we review the current understanding of the role of intestinal microbiota in the control of immune responses during aGVHD. Additionally, the possibility of using probiotic strains for potential treatment or prevention of aGVHD will be discussed.

Complete Resolution of Extensive Chronic Graft-Versus-Host Disease with Ibrutinib

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 5474-5474
Author(s):  
Audrey Scholoff ◽  
Gloria Obi ◽  
Kelty R. Baker ◽  
George Carrum ◽  
Rammurti T Kamble
Keyword(s):  
Graft Versus Host Disease ◽  
Complete Resolution ◽  
Conflicts Of Interest ◽  
Complete Response ◽  
Unrelated Donor ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Oral Ulcers

Abstract We herein document a complete response of extensive chronic graft-versus-host disease (cGvHD) to a Bruton's tyrosine kinase (BTK) inhibitor, ibrutinib. A 41 years old female with primary refractory MCL underwent mismatched unrelated donor (MMUD) allogeneic hematopoietic stem cell transplantation in December 2011 (conditioning with CY/TBI and alemtuzumab, graft=6.6x 106/kg CD-34+ cells, tacrolimus alone for GVHD prevention). Following engraftment on day 11, she developed grade III acute GvHD involving the skin and gut on day 17 of transplantation that persisted beyond 100 days post-transplant. Her cGvHD was treated with steroids, but remained active and extensive. Despite persistent cGvHD and 100% donor chimerism she relapsed in July 2012. Treatment with radiation and bendamustine with rituximab failed. By December 2013, the patient had extensive cGvHD manifesting as scleromatous skin thickening, oral ulcers and sclerosis of the buccal mucosa, ocular dryness and diarrhea, and was started on ibrutinib1 560 mg once daily for relapsed MCL. After 8 weeks of therapy, cGvHD had begun to improve. Oral steroids were reduced and ultimately stopped after 26 weeks of ibrutinib; after 30 weeks treatment all cGvHD manifestations resolved completely. A complete remission for MCL was documented at 8 weeks of ibrutinib initiation. Currently she continues to be on 560 mg daily ibrutinib without cGvHD exacerbation or MCL relapse for 22 weeks and 52 weeks, respectively. Chronic graft versus host disease (cGvHD) is mediated donor T cells. The role of B cells in the pathogenesis of cGvHD is increasingly recognized. Two murine studies have explored the role of ibrutinib in cGVHD-like syndromes, one in which there is T cell driven sclerodermatous cGvHD and a second in which there is Ab driven multiorgan system cGvHD that includes bronchiolitis obliterans (BO). Administration of ibrutinib decreased the incidence and severity of sclerodermatous, and improved pre-existing lesions and also improved pulmonary fibrosis and reduced BO. Animals lacking BTK and ITK did not develop cGVHD, indicating that these molecules are critical to cGVHD development. Our report provides the evidence that BTK inhibition led to complete resolution of cGvHD and supports exploration of its role in future clinical trials. Disclosures No relevant conflicts of interest to declare.

scholarly journals Role of CD8 Regulatory T Cells versus Tc1 and Tc17 Cells in the Development of Human Graft-versus-Host Disease

2017 ◽  
Vol 2017 ◽  
pp. 1-11 ◽  
Author(s):  
Adriana Gutiérrez-Hoya ◽  
Rubén López-Santiago ◽  
Jorge Vela-Ojeda ◽  
Laura Montiel-Cervantes ◽  
Octavio Rodríguez-Cortés ◽  
...  
Keyword(s):  
T Cells ◽  
Regulatory T Cells ◽  
Graft Versus Host Disease ◽  
Treg Cells ◽  
Protective Role ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Tc17 Cells

CD8+ T cells that secrete proinflammatory cytokines play a central role in exacerbation of inflammation; however, a new subpopulation of CD8 regulatory T cells has recently been characterized. This study analyzes the prominent role of these different subpopulations in the development of graft-versus-host disease (GVHD). Samples from 8 healthy donors mobilized with Filgrastim® (G-CSF) and 18 patients who underwent allogeneic hematopoietic stem cell transplantation (HSCT) were evaluated by flow cytometry. Mobilization induced an increase in Tc1 (p<0.01), Th1 (p<0.001), Tc17 (p<0.05), and CD8+IL-10+ cells (p<0.05), showing that G-CSF induces both pro- and anti-inflammatory profiles. Donor-patient correlation revealed a trend (p=0.06) toward the development of GVHD in patients who receive a high percentage of Tc1 cells. Patients with acute GVHD (aGVHD), either active or controlled, and patients without GVHD were evaluated; patients with active aGVHD had a higher percentage of Tc1 (p<0.01) and Tc17 (p<0.05) cells, as opposed to patients without GVHD in whom a higher percentage of CD8 Treg cells (p<0.01) was found. These findings indicate that the increase in Tc1 and Tc17 cells is associated with GVHD development, while regulatory CD8 T cells might have a protective role in this disease. These tests can be used to monitor and control GVHD.

Acute polymyositis presenting as chronic graft-versus-host disease: A systemic review.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e19025-e19025
Author(s):  
Abdul Basit ◽  
Moazzam Shahzad ◽  
Sibgha Gull Chaudhary ◽  
Fatima Khalid ◽  
Nausheen Ahmed ◽  
...  
Keyword(s):  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Graft Versus Host Disease ◽  
Systemic Review ◽  
Current Evidence ◽  
Hematopoietic Stem ◽  
Allogenic Stem Cell Transplantation ◽  
Host Disease ◽  
Graft Versus Host

e19025 Background: Chronic graft-versus-host disease (cGvHD) remains a significant complication of allogenic hematopoietic stem cell transplantation (allo-HSCT), with an estimated incidence of over 50%. Commonly targeted organs are skin, eyes, mouth, gastrointestinal tract, and liver. Muscular involvement and presentation as acute polymyositis (APM) remains a rare manifestation of cGvHD. We present a systemic review of APM associated with cGvHD to summarize current evidence regarding epidemiology, clinical presentation, diagnosis, treatment, and prognosis. Methods: A systemic review was conducting following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We screened 97 articles from 3 databases (PubMed, Embase, and Cochrane) using the MeSH terms and keywords for “Allogenic stem cell transplantation,” “Chronic graft-versus-host disease,” “Polymyositis” and “Myositis” from the date of inception to Jan 2021. After excluding duplicate, review and non-relevant articles, we included 36 studies (3 retrospective, others case series/reports) reporting APM associated with cGvHD after allo-HSCT. Results: We identified 72 patients, presented with APM associated with cGvHD after allo-HSCT. It involves cases of all ages, with male predominance. The onset of APM ranges as early as 100 days to 5 years, with a median range of 1.6 years post-allo-HSCT. Over half (59%) of patients had prior acute GvHD. Majority (85%) of cases presented with myalgia and progressive bilateral proximal muscle weakness with elevated Creatine phosphokinase (CPK) and/or Aldolase. Isolated presentation of APM without other manifestations of GvHD was rare, and concurrent skin involvement was present in 42% cases. Steroids remain the mainstay of treatment, achieving complete treatment response in up to 78% of cases. In some refractory cases, Rituximab has also been effective. Conclusions: APM can present as a sole manifestation of cGvHD with an estimated incidence of up to 3.4%. Diagnosis can be challenging as it can mimic idiopathic polymyositis. Radiologically targeted muscle biopsy showing characteristic myonecrosis remains the gold standard for diagnosis. Most (90%) cases respond to steroids and immunosuppression agents. Nevertheless, refractory cases remain challenging to treat and can cause significant morbidity and mortality. Characteristics of APM in 3 cohorts of allo-HSCT patients.[Table: see text]

MiR-146a Regulates the TRAF6/TNF-Axis in Donor T Cells during Graft-Versus-Host Disease

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 843-843
Author(s):  
Natalie Stickel ◽  
Gabriele Prinz ◽  
Dietmar Pfeifer ◽  
Annette Schmitt-Graeff ◽  
Marie Follo ◽  
...  
Keyword(s):  
T Cells ◽  
Graft Versus Host Disease ◽  
Acute Gvhd ◽  
Negative Regulator ◽  
Snp Analysis ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Donor T Cells

Abstract Introduction: Acute graft-versus-host disease (GvHD) arises from the attack of recipient tissues by donor allogeneic T cells and represents one of the major limitations of allogeneic hematopoietic cell transplantation (allo-HCT). In spite of many clinical trials, the standard immunosuppressive regimens for prevention of acute GvHD have improved little in the last two decades. Hence, a better understanding of the biology of acute GvHD may improve therapeutic options. MicroRNA-146a (miR-146a) was found to be increased in the sera of patients with GvHD. Therefore, we aimed to decipher the role of miR-146a in allogeneic donor T cells during GvHD by functional studies and in patients undergoing allo-HCT by single nucleotide polymorphism (SNP) analysis. Methods: We used two different murine major MHC mismatch models for acute GvHD. Recipient mice were conditioned with irradiation before transplantation of bone marrow and either wildtype or miR-146a deficient T cells from allogeneic donor mice. Furthermore, genomic DNA from 289 patients that underwent allo-HCT and their respective hematopoietic stem cell donors was isolated in order to determine their miR-146a rs2910164genotype. Results: We observed miR-146a upregulation in T cells of mice developing acute GvHD compared to untreated mice in a major MHC and a minor histocompatibility antigen mismatch model. Transfer of miR-146a deficient T cells caused increased GvHD severity, elevated TNF serum levels and reduced survival. Conversely, the phytochemical induction of miR-146a or its overexpression in donor T cells using a specific miR-146a mimic reduced GvHD severity. TNF receptor-associated factor 6 (TRAF6), a verified target of miR-146a, was upregulated in miR-146a-/- T cells following alloantigen stimulation. Higher TRAF6 levels translated into increased NF-κB activity and TNF production in miR-146a-/- T cells, while other pro-inflammatory cytokine levels were unaffected. The detrimental effect of miR-146a deficiency in T cells could be antagonized by TNF blockade in vivo. Moreover, in contrast to WT T cells, over expression of miR-146a in Tnf deficient T cells had no effect on their alloreactivity. In the human system, the minor genotype of the SNP rs2910164, which causes reduced miR-146a expression, was more frequent in patients developing acute GvHD grade III/IV compared to all other allo-HCT recipients (n=289). Conclusions: Taken together we show that miR-146a functions as a negative regulator of the TRAF6/TNF-axis in allogeneic donor T cells during GvHD, leading to reduced TNF transcription. Given our observation on the predictive role of the SNP leading to decreased miR-146a expression in acute GvHD in patients and the possibility to exogenously enhance miR-146a expression, we provide a novel and targeted molecular approach to mitigate GvHD. Disclosures No relevant conflicts of interest to declare.

scholarly journals Newly Found Peacekeeper: Potential of CD8+ Tregs for Graft-Versus-Host Disease

2021 ◽  
Vol 12 ◽  
Author(s):  
Weihao Wang ◽  
Tao Hong ◽  
Xiaoqi Wang ◽  
Rui Wang ◽  
Yuxuan Du ◽  
...  
Keyword(s):  
Graft Versus Host Disease ◽  
Cellular Therapy ◽  
Hematologic Malignancies ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Cytokine Levels ◽  
Underlying Mechanisms ◽  
Clinical Advances

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the most effective and potentially curative treatment for a variety of hematologic malignancies. However, graft-versus-host disease (GVHD) is a major obstacle that limits wide application of allo-HSCT, despite the development of prophylactic strategies. Owing to experimental and clinical advances in the field, GVHD is characterized by disruption of the balance between effector and regulatory immune cells, resulting in higher inflammatory cytokine levels. A reduction in regulatory T cells (Tregs) has been associated with limiting recalibration of inflammatory overaction and maintaining immune tolerance. Moreover, accumulating evidence suggests that immunoregulation may be useful for preventing GVHD. As opposed to CD4+ Tregs, the CD8+ Tregs population, which constitutes an important proportion of all Tregs, efficiently attenuates GVHD while sparing graft-versus-leukemic (GVL) effects. CD8+ Tregs may provide another form of cellular therapy for preventing GVHD and preserving GVL effects, and understanding the underlying mechanisms that different from those of CD4+ Tregs is significant. In this review, we summarize preclinical experiments that have demonstrated the role of CD8+ Tregs during GVHD and attempted to obtain optimized CD8+ Tregs. Notably, although optimized CD8+ Tregs have obvious advantages, more exploration is needed to determine how to apply them in the clinic.

scholarly journals Diagnostic and Prognostic Role of Fecal Calprotectin As a Biomarker for Gastrointestinal Graft Versus Host Disease: A Systematic Review of Literature

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5725-5725
Author(s):  
Abdul Rafae ◽  
Mustafa Nadeem Malik ◽  
Ali Younas Khan ◽  
Anum Qureshi ◽  
Muhammad Abu Zar ◽  
...  
Keyword(s):  
Systematic Review ◽  
Graft Versus Host Disease ◽  
Fecal Calprotectin ◽  
Cochrane Library ◽  
Prognostic Role ◽  
Hematopoietic Stem ◽  
Steroid Resistant ◽  
Host Disease ◽  
Graft Versus Host

Abstract Introduction: Graft versus host disease (GVHD) is the most significant complication after allogeneic hematopoietic stem cell transplantation (HSCT) and a leading cause of morbidity and mortality. The incidence of acute gastrointestinal graft versus host disease (GI-GVHD) in HSCT patients is reported between 40% to 50%. Fecal calprotectin (FC) has an established role as a diagnostic modality and a biomarker of disease activity in patients with inflammatory bowel disease (IBD). It has been suggested that FC may also play an important role in diagnosing and assessing the severity of GVHD and in determining resistance and response to corticosteroid treatment. Methods: To study the diagnostic and prognostic role of FC in GVHD patients, we performed a systematic review, 19 articles published after 2004 were selected from following four databases (PubMed, Embase, Cochrane Library and Web of Science). Numeric data were summarized using means, medians, and ranges. Categorical data were summarized using absolute values and percentages. Results: A total of 494 patients were included. Two hundred fifty two patients (51%) developed acute GVHD. Hundred seventy nine patients (71%) had GI-GVHD and 73 patients (29%) had non GI-GVHD. In one of the cohorts (n=21), median FC (mFC) levels were 198.9 mg/kg [range(r) =58.4-500] in patients with GVHD versus 32.2 mg/kg (r=15.6-89) in patients without GVHD (p=0.0005). In a similar cohort (n=23), mFC levels were 504 mg/kg in patients with GVHD and 107.4 mg/kg in patients without GVHD (p=<0.001). Five cohorts compared mFC level in GI-GVHD vs. non GI-GVHD patients and the results were as follows: 318 mg/kg (r=36-596) vs. 38 mg/kg (r=35.5-56), p=0.003 (61 patients); 595 mg/kg vs. 51.7 mg/kg, p=<0.001 (64 patients); 396.6 mg/kg (r=142.1-500) vs. 115.2 mg/kg (r=58.4-292.3), p=0.02 (14 patients); 500 mg/kg vs. 95 mg/kg , p=0.0229; 56 mg/kg vs. 121 mg/kg, p=0.67 (31 patients). In another cohort (n=40), mFC level was 193.9 mg/kg in patients with GI-GVHD as compared to mFC level of 53.1 mg/kg in patients with CMV colitis (p=0.017). In another cohort (n=14), mFC level was 134.9 mg/kg (r=58.4-292.3) in patients with grade I-II GVHD as compared to mFC level of 396.6 mg/kg (95.2-500) in patients with grade III-IV GVHD (p=0.029). In another cohort (n=54) with GI-GVHD, corticosteroids responsive patients had mFC level of 64 mg/kg (range 17-360) at onset and 49 mg/kg (range 12-238) at 1 week of treatment while corticosteroid resistant patients had mFC level of 488 mg/kg (range 65-835) at onset and 542 mg/kg (range 121-1080) at 1 week of treatment (p=0.028 at onset and p=0.038 at one week). In another cohort (n=7), mean FC level was 24 mg/kg (r=16-31) in steroid responsive patients as compared to mean FC level of 449 mg/kg (r=116-1111) in steroid resistant patients (p=0.032). Conclusions: Our analysis demonstrates that FC levels are higher in patients with GI-GVHD. Furthermore, a linear correlation is present between FC levels and severity of GVHD. FC levels are higher in patients with steroid-resistant GVHD and can be useful to determine treatment response. Data on FC levels in these patients seem promising and future randomized prospective trials are needed. Disclosures No relevant conflicts of interest to declare.

scholarly journals Fecal microbiota transplantation in the treatment of intestinal steroid-resistant graft-versus-host disease: two case reports and a review of the literature

2020 ◽  
Vol 48 (6) ◽  
pp. 030006052092569 ◽  
Author(s):  
Monika Maria Biernat ◽  
Donata Urbaniak-Kujda ◽  
Jarosław Dybko ◽  
Katarzyna Kapelko-Słowik ◽  
Iwona Prajs ◽  
...  
Keyword(s):  
Graft Versus Host Disease ◽  
Fecal Microbiota Transplantation ◽  
Case Reports ◽  
Fecal Microbiota ◽  
Drug Resistant ◽  
Candida Spp ◽  
Hematopoietic Stem ◽  
Steroid Resistant ◽  
Host Disease ◽  
Graft Versus Host

Acute graft-versus-host disease (aGvHD) reduces the efficiency and safety of allogeneic hematopoietic stem cell transplantation (allo-HSCT). In recent years, attempts have been made to transplant fecal microbiota from healthy donors to treat intestinal GvHD. This study presented two cases of patients undergoing allo-HSCT who were later selected for fecal microbiota transplantation (FMT). In the first patient, FMT resulted in the complete resolution of symptoms, whereas therapeutic efficacy was not achieved in the second patient. FMT eliminated drug-resistant pathogens, namely very drug-resistant Enterococcus spp., but not multidrug-resistant Acinetobacter baumannii or Candida spp. Further research is needed, particularly on the safety of FMT in patients with intestinal steroid-resistant GvHD and on the distant impact of transplanted microflora on the outcomes of allo-HSCT. FMT appears promising for the treatment of patients with steroid-resistant GvHD.

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