scholarly journals Kynurenine Pathway Activation and Deviation in Fibrosing Chronic Graft-Versus-Host Disease

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3895-3895
Author(s):  
Orsatti Laura ◽  
Thomas Stiehl ◽  
Katharina Dischinger ◽  
Roberto Speziale ◽  
Pamela Di Pasquale ◽  
...  
Keyword(s):  
Graft Versus Host Disease ◽  
Anthranilic Acid ◽  
Vitamin B6 ◽  
Research Funding ◽  
Serum Levels ◽  
Kynurenine Pathway ◽  
Vitamin B2 ◽  
Graft Versus Host ◽  
Increased Activity ◽  
Reduced Activity

Abstract Background: Fibrosing chronic graft-versus-host disease (cGVHD) is a debilitating complication after allogeneic stem cell transplantation (allo-SCT), and its pathophysiology is poorly understood. Kynurenine and its metabolites were shown to associate with both, interferon-gamma (IFNg) activation and fibrosis. This study investigates the interplay between members of the IFNγ pathway and Kynurenin-derived metabolites in cGVHD. Methods: Using a liquid chromatography tandem mass spectrometry approach on sera obtained on day+100 (n=430) and/or at onset of cGVHD symptoms (n=196) of our prospectively collected biobank after alloSCT, we measured concentrations of Kyn pathway metabolites (kynurenin (Kyn), anthranilic acid (AA), kynurenic acid (KA), 3-hydroxykynurenine (3-HK), and 3-hydroxy-anthranilic acid (3-HAA). We also measured C-X-C chemokine ligand 9 (CXCL9), interleukin (IL-)18, tryptophane (Trp) and indoleamine-2,3-dioxygenase (IDO) by ELISA. Results: We observed increased CXCL9 and IDO levels, and increased activity of the Kynurenine pathway in both non-severe and severe cGVHD. Interestingly, severe fibrosing cGVHD differed from any other form of cGVHD in a significant pathway shift toward AA and KA. This resulted in a reduced 3-HAA/AA ratio. A score consisting of low 3-HAA/AA ratio and high KA serum levels at onset of mild cGVHD symptoms predicted risk specifically of severe fibrosing cGVHD. This altered pathway in severe fibrosing cGVHD correlated with reduced activity of the Vitamin-B2-dependent kynurenine monooxygenase, low vitamin B6, and increased interleukin-18. Our results are consistent with a triple-hit model for fibrosing cGVHD including low activity of kynurenine monooxygenase (KMO, Vitamin B2 and B6 dependent) in the context of high IL18 serum levels and CXCL9-induced IDO activation (Figure 1). Conclusion: Chronic GVHD associates with an IFNg signature and increased activity of the Kynurenin pathway. KA and 3-HAA/AA defined the first molecular distinction between fibrosing and non-fibrosing cGVHD. The mechanism may involve Vitamin B2/B6 deficiency, and high CXCL9 and IL18. The Kyn metabolite signature is a candidate biomarker for severe fibrosing cGHVD and provides a rationale for translational trials on prophylactic Vitamin B2/B6 supplementation for cGVHD prevention. Figure 1: Triple hit model of fibrosing cGVHD (Hypothesis): Severe fibrosing cGVHD associates with a strong CXCL9-induced activation of IDO. The result of this activation is influenced by a reduced activity of kynurenine monooxygenase (KMO), either due to genetic polymorphisms or lack of Vitamin B2, and further aggravated by lack of Vitamin B6. The resulting metabolic deviation increases AA concentrations and reduces the 3-HAA/AA ratio. Finally, high IL-18 associates with increased serum KA. These three hits result in a metabolic situation with high KA and a low ratio 3-HAA/AA that predicts risk of fibrosing cGVHD. Figure 1 Figure 1. Disclosures Mueller-Tidow: Janssen Cilag: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Bioline: Consultancy, Research Funding.

scholarly journals Tocilizumab Is Highly Active for Severe Steroid-Refractory Acute Graft-Versus-Host Disease of the Gastrointestinal Tract

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2245-2245 ◽  
Author(s):  
Alex Ganetsky ◽  
Noelle V Frey ◽  
Alison W Loren ◽  
Elizabeth O. Hexner ◽  
James K Mangan ◽  
...  
Keyword(s):  
Inflammatory Cytokines ◽  
Graft Versus Host Disease ◽  
Research Funding ◽  
Hematologic Malignancy ◽  
Serum Levels ◽  
Graft Versus Host ◽  
Highly Active ◽  
Steroid Refractory ◽  
Acute Graft ◽  
Pro Inflammatory Cytokines

Abstract Introduction: Severe steroid-refractory (SR) gastrointestinal acute graft-versus-host disease (GI-GVHD) is associated with significant mortality in allogeneic hematopoietic cell transplantation (HCT) recipients. Although numerous agents have been studied for this indication, long-term outcomes remain dismal. Tocilizumab, an interleukin-6 receptor monoclonal antibody, is active in SR GI-GVHD with varying efficacy and impact on survival. Tocilizumab was recently adopted at our center as initial therapy for SR GI-GVHD. Methods: We retrospectively evaluated the efficacy of tocilizumab for the treatment of SR biopsy-proven GI-GVHD in 5 consecutive adult allogeneic HCT recipients between October 2015 and July 2016. All patients had stage IV GI GVHD (Glucksberg criteria) without other organ involvement at time of tocilizumab initiation. Three patients underwent myeloablative conditioning and two reduced-intensity conditioning for a hematologic malignancy (AML n=3; ALL n=1; myelofibrosis n=1). SR GI-GVHD was defined as progressive symptoms after 3 days or no improvement after 7 days of methylprednisolone 2 mg/kg/day. Tocilizumab 8 mg/kg was administered approximately every 2 weeks until achievement of complete response (CR), defined as resolution of all manifestations of GI GVHD, progression or initiation of other therapy. Serum levels of pro-inflammatory cytokines (IFN-γ, IL-2, IL-2R, IL-6, IL-7, IL-15, TNF-α) were measured prior to and after the start of tocilizumab using multiplex arrays. Results: All 5 patients (100%; 95% CI, 0.52 - 1.00) achieved a CR after a median time of 9 days (range, 8 - 13) from tocilizumab initiation. The median time to response onset (improvement in GVHD stage by at least 1) was 1 day (range, 1 - 2). Tocilizumab was administered at a median of 17 days (range 8 - 25) from GVHD diagnosis and 15 days (range, 7 - 18) from initiation of high-dose steroids. The median number of tocilizumab doses administered was 2 (range, 1 - 4). Two patients achieved CR after a single dose and 3 patients required multiple doses of tocilizumab to achieve CR (2 doses n=1; 3 doses n=1; 4 doses n=1). At a median follow up of 5.6 months (range, 2.1 - 8.5) from initiation of tocilizumab, 3 of 5 patients are alive and free of their underlying hematologic malignancy. One patient died from complications related to biopsy-proven liver GVHD that developed after tocilizumab initiation and 1 patient died from polymicrobial sepsis. Serum levels of IL-6 prior to the start of tocilizumab ranged from 4 - 21 pg/mL (normal 0 - 12). As all patients responded, no associations between serum levels of pro-inflammatory cytokines, including IL-6, and tocilizumab response could be identified. Conclusion: Tocilizumab appears to be a highly active agent for the treatment of SR GI-GVHD. Detailed evaluation through prospective clinical trials is warranted. Disclosures Frey: Servier: Consultancy; Amgen: Consultancy; Novartis: Research Funding. Mangan:Incyte: Other: Advisory Board; Novartis: Research Funding. Gill:Novartis: Patents & Royalties, Research Funding. Cohen:Bristol-Meyers Squibb: Consultancy, Research Funding; Janssen: Consultancy. Porter:Novartis: Patents & Royalties, Research Funding; Genentech: Other: Spouse Employment.

scholarly journals Predictors and Outcomes of Flares in Chronic Graft-Versus-Host Disease

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 47-48
Author(s):  
Grigori Okoev ◽  
Daniel J. Weisdorf ◽  
John E Wagner ◽  
Bruce R. Blazar ◽  
Margaret L. MacMillan ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Board Of Directors ◽  
Graft Versus Host Disease ◽  
Research Funding ◽  
Time Dependent ◽  
Advisory Committees ◽  
Graft Versus Host ◽  
Day Range ◽  
Similar Risk ◽  
Fund Research

Introduction: Chronic Graft-versus-Host Disease (cGvHD) frequently requires prolonged immune suppressive therapy (IST) with > 50% still on IST at 5 years. The IST typically involves a slow taper of steroids often with flare of cGvHD, necessitating augmentation of previous therapy or addition of new IST. Studies describing cGvHD flares are limited. We analyzed patients with cGvHD who flared during the treatment with systemic IST, their overall survival (OS) and non-relapse mortality (NRM). Methods: This study included all adult patients with cGvHD (n=145) following an allogeneic transplant (2010 - 2017) from a matched sibling donor peripheral blood stem cell transplant (MSD, n=104 (72%) or double/single umbilical cord blood transplant (UCBT, n=41 (28%). The 2014 NIH Consensus Criteria were used to classify organ/overall cGvHD severity. Flare of cGvHD was defined as progression in cGvHD manifestations (after initial response), which was less severe than at diagnosis. Multivariate regression of flares was based on the Prentice, Williams and Peterson model for ordered multiple events (flares). Time-dependent effects on OS and NRM were analyzed by Cox and Fine and Gray regression with propensity scoring to control for confounding. Results: Flares occurred in 87 patients; the cumulative incidence of flares was 60% (95% CI: 51-70%) at a median of 188 days (range 16-751) after diagnosis of cGvHD. The median dose of prednisone was 1 mg/kg/day (range 0-4.2) at diagnosis of cGvHD. At the diagnosis of flare, 36 (41%) of the patients were off prednisone, 50 (57%) were receiving 0.1-0.5 mg/kg /day, and 2 patients > 0.5 mg/kg /day. Thirty two of the 87 (36%) patients experienced multiple flares (2 to 4). The most common organs involved at cGvHD flare were skin (n=45; 51%), mouth (n=27; 31%), GI tract (n=22; 25%) and liver (n=12; 14%); often in combinations of skin/mouth in 11 cases (13%), skin/GI in 6 (7%) and liver/mouth in 4 (5%) cases. Treatment for flare was mostly increase in dose of prednisone to 0.5 mg/kg/day (range 0.3-1.0) in 77 patients (88%) plus the addition of another line of IST in 48 patients (55%). In multiple regression analysis, only donor type was significant predictor of flare in cGvHD. UCBT was associated with 2-fold lower probability of flaring (HR 0.5; 95% CI: 0.3-0.9; p=0.03) compared to MSD. cGvHD severity, organ involvement, platelet count at diagnosis and type of onset were not significant predictors of cGvHD flares. At 2 years after the initial flare, the OS was 77% (95% CI: 66-84%) and NRM 19% (95% CI: 11-28%). Multiple regression analysis evaluating OS and NRM from onset of cGvHD comparing flare to non-flare were performed using flare as a time dependent variable. Compared to cGvHD patients without flare at 2 years, those with flare of cGvHD had a similar risk of NRM (HR 1.2; 95% CI: 0.2-6.1, p=0.86) and OS (HR 0.9; 95% CI: 0.4-2.3, p=0.85). At 2 years from cGvHD onset, the cumulative incidence of resolved cGvHD (durable discontinuation of steroids for ≥ 6 consecutive months) was 31% (95% CI: 21-41%) in those who flared vs. 86% (95% CI: 75-96%) in those without flare. Conclusions: Though cGvHD patients with flare had similar risk of NRM and OS as those without a flare, patients with flare required extended steroids, along with clinical monitoring and intensified IST. cGvHD after UCBT was associated with significantly lower risk of flaring compared to MSD. The ongoing burden of IST, risk of infection and morbidity of cGvHD is substantial and needs better approaches than chronic slow taper of steroids. Disclosures Weisdorf: Incyte: Research Funding; FATE Therapeutics: Consultancy. Wagner:Novartis: Research Funding; Rocket Pharmaceuticals, Inc.: Consultancy, Current equity holder in publicly-traded company; Magenta Therapeutics: Consultancy, Research Funding; BlueRock: Research Funding; Gadeta: Membership on an entity's Board of Directors or advisory committees. Blazar:Fate Therapeutics Inc.: Research Funding; Childrens' Cancer Research Fund: Research Funding; BlueRock Therapeutics: Research Funding; BlueRock Therapeuetic: Consultancy; Magenta Therapeutics: Consultancy; KidsFirst Fund: Research Funding; Tmunity: Other: Co-founder. MacMillan:Mesoblast: Consultancy; Angiocrine Biosciences, Inc.: Consultancy; Equillium, Inc.: Consultancy; Talaris Therapeutics, Inc: Consultancy; Fate Therapeutics, Inc.: Consultancy. Holtan:Generon: Consultancy; BMS: Consultancy; CSL Behring: Other: Clinical trial data adjudication; Incyte: Consultancy. Brunstein:AlloVir: Other: Advisory board; Gamida: Research Funding; Astex: Research Funding; Magenta: Research Funding. Betts:Patent Pending: Patents & Royalties: Dr. Betts has a pending patent WO2017058950A1: Methods of treating transplant rejection. This includes the use of JAK inhibitors. Neither he nor his institution have received payment related to claims described in the patent.. Bachanova:FATE: Research Funding; Karyopharma: Membership on an entity's Board of Directors or advisory committees; Incyte: Research Funding; Gamida Cell: Membership on an entity's Board of Directors or advisory committees, Research Funding; Kite: Membership on an entity's Board of Directors or advisory committees; BMS: Research Funding. Rashidi:Synthetic Biologics: Other: DSMC member (1 trial) and related honorarium. Arora:Fate Therapeutics: Consultancy; Kadmon: Research Funding; Pharmacyclics: Research Funding; Syndax: Research Funding.

scholarly journals Outcomes Following Intolerance to Tacrolimus/Sirolimus for Graft-Versus-Host Disease Prophylaxis in Allogeneic Hematopoietic Stem Cell Transplant

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 5673-5673
Author(s):  
Sayeef Mirza ◽  
Ankita Tandon ◽  
Dakota Jenneman ◽  
Shu Cao ◽  
Ambuj Kumar ◽  
...  
Keyword(s):  
Graft Versus Host Disease ◽  
Research Funding ◽  
Categorical Variables ◽  
Cell Transplant ◽  
Host Disease ◽  
Graft Versus Host ◽  
Allogeneic Hct ◽  
Gvhd Prophylaxis ◽  
Days Of Therapy ◽  
Grade Ii

INTRODUCTION: Graft-versus-host disease (GVHD) is a major complication of allogeneic hematopoietic cell transplant (HCT) resulting in significant morbidity and mortality. The combination of tacrolimus and sirolimus (TAC/SIR) has emerged as a GVHD prophylaxis platform preferred by many institutions given its association with rapid engraftment and acceptable transplant-related toxicity. However, overlapping toxicities between the two drugs can lead to intolerance and premature discontinuation in some patients. There is limited literature describing outcomes and subsequent management of such patients. The goal of this study is to investigate the clinical outcomes of patients becoming intolerant to the combination of TAC/SIR prophylaxis. METHODS: We retrospectively evaluated consecutive adult patients (n=100) at the Moffitt Cancer Center who received allogeneic HCT with TAC/SIR for GVHD prophylaxis in 2018. TAC/SIR intolerance was defined as discontinuation due to the toxicity of either TAC or SIR before post-transplant day 100. Survival analyses were estimated from the time of transplant with the Kaplan-Meier method and compared using the log-rank test. Patients intolerant of this prophylaxis regimen were compared to patients who completed >100 days of therapy, using Mann-Whitney U test for continuous variables and Pearson Chi-square tests for categorical variables. All statistical analyses were performed using SPSS v25 and NCSS v11. RESULTS: Demographics and clinical characteristics of all patients are summarized in Table 1A. TAC/SIR intolerance occurred in 25% (24 discontinued TAC, 1 discontinued SIR) of patients at a median duration of therapy of 19 days (range 4-92). The most common TAC/SIR toxicity (Table 1B) was acute kidney injury (AKI, n=11, 44%), followed by thrombotic microangiopathy (TMA, n=3, 12%). Baseline metabolic and clinical variables including creatinine, liver function, and conditioning intensity were not predictive of TAC-SIR intolerance. At a median follow-up of 10 months, the median overall survival (OS) for patients intolerant of TAC/SIR was 10 months versus was not reached for the patients without intolerance (HR 5.42; 95% CI 1.71-17.14; p<0.001). The 1-year PFS was 16% (95% CI 0% - 42%) vs 75% (95% CI 65% - 86%) and OS was 35% (95% CI 8% - 63%) vs. 79% (95% CI 68% - 90%) for patients who were TAC/SIR-intolerant compared to those who were TAC/SIR-tolerant (p<0.01) (Figure 1A). The cumulative incidence (CuI) of non-relapse mortality (NRM) at 1 year in patients intolerant of TAC/SIR was 47% (95% CI: 28% - 81%) and in patients tolerant of TAC/SIR was 4.4% (95% CI: 1.5% - 14%), (p<0.001). The Cul of relapse at 1 year was 45% (95% CI: 20% - 100%) in patients who were TAC/SIR-intolerant compared to 18% (95% CI: 10% - 30%) in patients who tolerated TAC/SIR (p=0.07) (figure 1B). Overall, 31 patients (31%) developed grade II-IV acute GVHD (aGVHD). The Cul of grade II-IV aGVHD at 100 days in patients who were TAC/SIR-intolerant was 29% (95% CI 15% - 58%) compared to 17% (95% CI 10% - 29%) in patients who tolerated TAC/SIR, (p=0.38). The Cul of cGVHD at 1 year in patients who were TAC/SIR-intolerant was 44% (95% CI: 25% - 79%) compared to 52% (95% CI: 40% - 68%) in patients who were TAC/SIR-tolerant (p=0.89). CONCLUSIONS: Outcomes for patients completing over 100 days of TAC/SIR for GVHD prophylaxis following allogeneic HCT are favorable. However, early intolerance of TAC/SIR GVHD prophylaxis occurred in 25% of allogeneic HCT in 2018 alone and predicted a poor prognosis with increased NRM and overall mortality, largely from drug-related toxicities. Notably, premature discontinuation of TAC/SIR did not contribute to higher subsequent risks of GVHD. Strategies to mitigate the risks of TAC/SIR toxicity are warranted. Future studies are also needed to identify the optimal GVHD prophylactic regimen for patients after TAC/SIR intolerance. Disclosures Nishihori: Novartis: Research Funding; Karyopharm: Research Funding. Bejanyan:Kiadis Pharma: Other: advisory board.

Host γd T cells Exacerbate Experimental Acute Graft-Versus-Host Disease through Activation of Host Antigen Presenting Cells.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 3045-3045
Author(s):  
Yoshinobu Maeda ◽  
Pavan Reddy ◽  
Chen Liu ◽  
D. Keith Bishop ◽  
James L.M. Ferrara
Keyword(s):  
T Cells ◽  
T Cell ◽  
Mhc Class Ii ◽  
Graft Versus Host Disease ◽  
Serum Levels ◽  
Host Disease ◽  
Graft Versus Host ◽  
Full Intensity

Abstract Large numbers of T cells bearing γd T cell receptors are present in graft-versus-host disease (GVHD) target tissues. We investigated the potential role of host γd T cells during acute GVHD in a well-characterized GVHD model following full intensity conditioning (11 Gy TBI). BM and spleen T cells from BALB/c (H2d) donors were transplanted into wild type (wt) B6, aß T cell deficient B6 (aß −/−) or γd T cell deficient B6 (γd −/−) hosts. γd −/− hosts demonstrated significantly better day 35 survival (85%) than wt (40%) or aß−/− hosts (18%) (P<0.05). Reconstitution of γd −/− B6 hosts with B6 type γd T cells 24 hr prior to BMT restored lethal GVHD (50 % day 35 survival). In vivo, γd −/− B6 hosts demonstrated at least a five fold reduction in donor T cell expansion and cytokine production. In vitro, T cells proliferated less when co-cultured with allogeneic γd −/− dendritic cells (DCs) than with wt DCs (40,127 ± 1634 vs. 72,503 ± 1296, P<0.05). BM-derived DCs cultured with γd T cells caused greater proliferation of allogeneic T cells than DCs cultured with aß T cells (15.1 ± 21 x 104 vs. 5.1 ± 1.2 x 104, P<0.05). We next tested the effect of γd T cells on host DCs in vivo using a model system in which only the DCs injected prior to BMT expressed the alloantigen that stimulated the GVHD reaction. MHC Class II −/− B6 mice that had been depleted of γd T cells were given 11 Gy TBI and injected one day prior to BMT with B6 DCs that had been co-cultured either with γd T cells or with medium. On day 0 both groups of recipient mice were injected with BM plus splenic T cells from allogeneic bm12 donors. On day +5, CD4+ donor T cells expanded four times more in recipients of DCs co-cultured with γd T cells than in recipients of control DCs and serum levels of TNF-a were significantly higher (36.7 + 6.8 vs. 21.3 + 3.7 pg/ml, P<0.05). Together these data demonstrate that γd T cells amplify the stimulatory function of host DCs and increase the severity of GVHD, suggesting that a new therapeutic target for the prevention of the major BMT toxicity.

Tryptophan Metabolites Analogue, N-(3,4-dimethoxycinnamonyl) Anthranilic Acid, Ameliorates Acute Graft-Versus-Host Disease Through Inhibiting Th1 Responses

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 5421-5421
Author(s):  
Jinhuan Xu ◽  
Yicheng Zhang
Keyword(s):  
T Lymphocytes ◽  
Graft Versus Host Disease ◽  
Anthranilic Acid ◽  
Allogeneic Bone Marrow Transplantation ◽  
Enzyme Linked Immunosorbent Assay ◽  
Allogeneic Bone ◽  
Host Disease ◽  
Graft Versus Host ◽  
Ifn Γ ◽  
Acute Graft

Abstract Local catabolism of tryptophan (Trp) by indoleamine 2,3-dioxygenase (IDO) is considered an important mechanism of regulating T cell immunity. N-(3,4-dimethoxycinnamonyl) anthranilic acid (3,4-DAA) is an active synthetic anthranilic acid derivative which was proved to be effective to treat type±helper T lymphocytes (Th1) mediated autoimmune diseases such as multiple sclerosis. In this report, we investigated the effects of 3,4-DAA on the acute graft versus host disease (aGVHD) following allogeneic bone marrow transplantation (allo-BMT) and its potential mechanism of action. we established a murine aGVHD model, 3,4-DAA was injected intraperitoneally at 200 mg/kg/day per mouse immediately after allo-BMT or at the onset of aGVHD for 14 consecutive days; the signs of aGVHD and the survival were recorded periodically; the histological changes of target organs were evaluated with hematoxylin-eosin staining; the IDO activity and cytokine levels in plasma were measured by reverse-phase high-performance liquid chromatography (HPLC) and enzyme linked immunosorbent assay (ELISA), respectively. We revealed that administration of 3,4-DAA after allo-BMT significantly reduced the severity and the histological score of aGVHD; The survival for mice receiving 3,4-DAA prophylaxis and treatment were prolonged in comparison to the vehicle control mice. The plasma levels of IFN-γ, TNF-α, IL-12 and IL-2 in 3,4-DAA treatment group were found to be decreased, while the IDO activity, the IL-10, IL-5 and IL-4 levels elevated in these mice. In consistent with the in vivo results, 3,4-DAA also inhibited IFN-γ and IL-2 production of spleen T lymphocytes in vitro. Our findings suggest that 3,4-DAA can diminish the murine experimental aGVHD through inhibition of Th1 response; this property makes it a potential alternative agent for prevention and treatment of GVHD in the clinic. Disclosures: No relevant conflicts of interest to declare.

Response to JAK 1/2 Inhibition in Patients with Corticosteroid-Refractory Acute Graft-Versus-Host Disease

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 3934-3934 ◽  
Author(s):  
Silvia Spoerl ◽  
Kristina Maas-Bauer ◽  
Mareike Verbeek ◽  
Petya Apostolova ◽  
Anna Lena Illert ◽  
...  
Keyword(s):  
Graft Versus Host Disease ◽  
Chronic Gvhd ◽  
Complete Response ◽  
Serum Levels ◽  
Salvage Treatment ◽  
Hematopoietic Stem ◽  
Host Disease ◽  
Graft Versus Host ◽  
Number Of Patients

Abstract Acute corticosteroid-refractory graft-versus-host-disease (GvHD) is a life-threatening complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT) with reported mortality rates of 40-60%. Our previous study (Spoerl S et al. Blood 2014) had shown the induction of tolerogenic regulatory T cells after ruxolitinib treatment in the mouse and clinical responses in six patients with corticosteroid-refractory GvHD. Here we report the outcome of 14 patients with GvHD refractory to steroids and at least two other lines of treatment who received ruxolitinib as a salvage treatment. Ten patients were classified as acute and four as chronic GvHD involving the skin, intestinal tract and liver as detailed in Table 1. Patients were treated with ruxolitinib at a starting dose of 5 mg orally twice daily with a dose increase to 10 mg orally twice daily. Clinical and histopathological grading of skin, intestinal and liver GvHD was performed according to established criteria. Of 14 patients, 13 responded with respect to clinical GvHD symptoms and serum levels of pro-inflammatory cytokines. Three patients with histologically proven acute skin or intestinal GvHD grade I, achieved a complete response. One non-responder discontinued ruxolitinib after one week because of lack of efficacy. In all other patients corticosteroids could be reduced after a median treatment of 1.5 weeks. Serum levels of IL-6 and soluble IL-2R were measured prior and after the start of ruxolitinib and declined in the majority of the analyzed patients (n=11). CMV reactivation was observed in four out of 14 patients and responded well to antiviral therapy. Two out of 14 patients developed cytopenia during ruxolitinib treatment that was mild and did not require dose reduction or transfusion. Our results indicate that treatment of corticosteroid-refractory GvHD with ruxolitinib is safe and well tolerated. Despite the low number of patients treated so far, our results demonstrate that ruxolitinib reduces the severity of corticosteroid-refractory GvHD and support further development of therapeutic JAK1/2 inhibition as a salvage treatment in GvHD. Table 1: GvHD and response to ruxolitinib Pt. no. 1 GvHD: organ/grade 2 Reduction of cortico-steroids after ruxolitinib Clinical response (PR / CR) 3 Time to response (weeks) Duration of response 4 / Current follow up (weeks) 5 01 Intestines / IV (acute) Yes CR 1 42 / 43 02 Skin / III (acute) Yes PR 1.5 46.5 / 48 03 Skin / IV liver / III (acute) Yes CR 1 57 / 58 04 Skin / III intestines / IV (acute) Yes PR 1.5 24.5 / 26 05 Skin / III (chronic) Yes PR 1 64 / 65 06 intestine/III-IV (acute) Yes PR 1 15 / 16 07 Skin/ III (chronic) Yes Response 1 46 / 47 08 Skin/ III (acute) Yes Response 1 2 / 3 09 Skin/ II intestine/II (chronic) Yes No response stopped after 1 week N/A N/A 10 Skin/ III liver/III (acute) Yes PR 1 1 / 2 11 intestines IV (acute) Yes PR 2 6 / 8 12 Skin/III (chronic) Yes Response 1 8 / 9 13 intestines/IV Skin/ II (late onset acute) Yes CR 1 17 / 18 14 intestines/IV Skin/ II (acute) Yes PR 1,5 3 / 4 1Pt.: patient, no: individual patient number, 2Acute and chronic GvHD were defined according to NIH criteria, 3PR: partial response, CR: complete response; 4Until last follow up, none of the patients experienced a relapse of GvHD. 5Follow up was calculated from the time of initiation of ruxolitinib treatment. In patient 01, ruxolitinib was discontinued at week 16 because of complete resolution of all GvHD signs. The patient did not develop any signs of GvHD after discontinuation of ruxolitinib until last follow up. Disclosures Off Label Use: Ruxolitinib in GvHD.

Systems Immune Monitoring with Mass Cytometry Characterizes Altered Peripheral Immune Cell Environments in Patients with Chronic Graft Versus Host Disease

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4572-4572 ◽  
Author(s):  
Hannah G. Polikowsky ◽  
Michael T. Byrne ◽  
Caroline E. Maier ◽  
Allison R. Greenplate ◽  
Madan H. Jagasia ◽  
...  
Keyword(s):  
B Cells ◽  
Clinical Research ◽  
Graft Versus Host Disease ◽  
Peripheral Blood ◽  
Research Funding ◽  
Immune Monitoring ◽  
Mass Cytometry ◽  
Computational Tools ◽  
Graft Versus Host ◽  
Treatment Responses

Abstract Introduction: Allogeneic stem cell transplant (SCT) fundamentally alters the immune milieu of an individual and provides a curative treatment for patients with blood cancer. However, a common side effect of SCT is the development of chronic graft versus host disease (cGVHD). Given the growth of new experimental therapeutics for GVHD, a systems immune monitoring approach based on mass cytometry analysis of peripheral blood may provide a robust and minimally invasive way to characterize the post-SCT cGVHD immune environment and systematically track cellular biomarkers of immune status, disease severity, or ongoing treatment responses (Greenplate et al., Euro J Cancer 2016, Kordasti et al., Blood 2016). It may also be possible to identify shifts in the immune milieu or cell signaling that predict treatment responses or stratify risks (Greenplate et al., Cancer Immunol Res 2016). This study tested the feasibility of using mass cytometry peripheral blood analysis in clinical research with the goals of 1) better understanding the post-SCT and cGVHD immune environment and 2) developing a knowledge base for monitoring treatment responses. Methods: Peripheral blood mononuclear cells (PBMC) were collected with informed consent from cGVHD patients or healthy donors with approval of the local Institutional Review Board (IRB) and in accordance with the Declaration of Helsinki. A total of 88 viably cryopreserved PBMC samples were analyzed from 11 individual patients undergoing extracorporeal photopheresis (ECP) therapy. For each patient, PBMC from 4 clinical timepoints representing pre-ECP and 2, 4, and 6 months post-ECP were characterized with 2 systems immune monitoring antibody panels emphasizing B cells and T cells (Table 1). Staining, data collection using a CyTOF mass cytometer, bead based normalization, and analysis with Cytobank software followed established protocols (Leelatian et al., Methods Mol Bio 2016, Polikowsky et al., J Immunol 2015). Next, cell subsets were algorithmically revealed and characterized by computational tools (Diggins et al., Methods 2015) and patterns in the abundance and phenotype of T, B, NK, and myeloid cell subsets systematically compared to patient clinical features. Results: Single cell tools revealed profound, abnormal shifts in the peripheral immune environment in individual patients that contrasted with relatively stable immunophenotypes observed in healthy individuals and prior studies. Expected immune changes, such a profound loss of B cells post-treatment with Rituximab, were readily detected by computational tools and expert review. Expression of signaling, activation, and subset identity markers in B and T cell subsets displayed striking variation between patients and was effectively quantified on at least 5 major cell subsets and numerous minor cell subsets (Figure 1). These data highlighted how computational tools paired with high-dimensional mass cytometry can systematically characterize key protein features and cell subsets in complex and heterogeneous diseases including cancer and cGVHD and provided a rationale for ongoing association analyses between cellular subsets and clinical outcomes. Conclusion: Systems immune monitoring successfully revealed shifts in cell abundance and immunophenotype pre- and post-ECP for patients with cGVHD. These shifts were detected by computational tools and revealed alterations to the immune system following treatment. This study indicates that single cell quantitative analysis is feasible as a clinical research tool to characterize immunotherapy treatment responses, and reveal cellular biomarkers. Integration of such tools in prospective clinical trials is essential to establish and once validated, may augment physician decision making. Disclosures Polikowsky: Cytobank: Employment. Greenplate:Cytobank: Consultancy. Jagasia:Therakos: Consultancy. Irish:Cytobank, Inc.: Equity Ownership, Membership on an entity's Board of Directors or advisory committees; Janssen: Research Funding; Incyte: Research Funding.

scholarly journals Signal Transducing Adaptor Protein (STAP) Family Accelerates Gut and Thymic Graft-Versus-Host-Disease in Murine Model

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4516-4516
Author(s):  
Hideaki Saito ◽  
Michiko Ichii ◽  
Jun Toda ◽  
Yuichi Kitai ◽  
Ryuta Muromoto ◽  
...  
Keyword(s):  
T Cells ◽  
Graft Versus Host Disease ◽  
Murine Model ◽  
Research Funding ◽  
Immune Reconstitution ◽  
Adaptor Protein ◽  
Treg Cells ◽  
Hematopoietic Stem ◽  
Graft Versus Host

Abstract Graft-versus-host-disease (GVHD) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the most frequent complication and one of the major causes of non-relapse mortality. However, its pathogenesis has not yet been fully understood. We cloned signal-transducing adaptor protein (STAP)-2 as a c-fms binding protein from a fetal liver library in 2003. The family that contains STAP-1 and STAP-2 has a pleckstrin homology (PH) and Src-homology 2 (SH2)-like domains, suggesting that this adapter protein functions as an immune and inflammatory regulator. Indeed, STAP-2 regulates adhesion and chemotaxis in T cells (Sekine et al., J Immunol. 2009). In this study, we aimed to elucidate the roles of STAP family in GVHD. First, we examined the expression of STAP-1 and STAP-2 mRNA in various human hematopoietic subsets, including CD34+ CD38- hematopoietic stem cells (HSCs), CD34+ CD38+ hematopoietic progenitor cells (HPCs), CD19+ CD27- naïve B cells, CD19+ CD27+ memory B cells, CD3+ CD4+ helper T-cells, and CD3+ CD8+ cytotoxic T lymphocytes, using real-time PCR. As a result, STAP-1 and STAP-2 were expressed in lymphoid cells, as well as HSCs and HPCs. STAP-2 mRNA was highly expressed in T cells. Next, to investigate the role of STAPs in GVHD, we made an experimental murine model. To study the pathogenesis of immune reconstitution and tolerance after allo-HSCT, lethally irradiated BALB/c mice were injected with T and B cell-depleted bone marrow cells (5×106 cells) derived from syngeneic BALB/c or allogeneic C57BL/6 mice on day 0. Co-transplantation of splenocytes was not adapted in this model. Survival and clinical degree of GVHD were assessed by a scoring system that sums changes in 5 clinical parameters: body weight (BW) loss, posture, activity, fur texture, and skin integrity. Recipients transplanted from allogenic wild type (WT) C57BL/6 donor survived without suffering from severe GVHD symptoms, owing to development of immune tolerance against allogeneic antigens. However, compared to syngeneic transplanted mice, these recipients started to show gradual BW loss and GVHD score was increased approximately 28 days after allo-HSCT, indicating the existence of an allogeneic immune reaction. To evaluate the role of STAPs in GVHD, we generated transgenic mice (Tg) that overexpress STAP under the control of Em enhancer and Lck proximal promoter. The promoter could drive expression of the inserted cDNA in lymphoid lineage cells from the common lymphoid progenitor (CLP) stage. When STAP-2 Tg marrow was used as a donor source, we found that the overall survival of STAP-2 Tg recipients was significantly lower than that of WT recipients (22.2% and 91.7%, respectively; p<0.001) on day 60. STAP-2 Tg recipients showed decreased BW and had a higher clinical GVHD score with statistical significance compared to control WT recipients. The overexpression of STAP-1 also exacerbated the severity of GVHD. At day 42, BW was decreased by 16.3% in WT recipients. In contrast, recipients of STAP-1 Tg and the STAP-2 Tg donor showed more severe BW loss along with diarrhea (23.3% and 29.8%, respectively). STAP-1 as well as STAP-2 Tg recipients showed significantly worsened GVHD scores, and this lasted until day 90 at the end of follow-up. In histologic examination of both STAP Tg recipients, inflammatory damages with lymphocyte infiltration were most notably observed in the colon. Interestingly, we found that thymus was atrophic or indistinguishable and the cortico-medullary junction disappeared. Moreover, compared to control WT recipients, the number of CD4+ CD25+ regulatory T (Treg) cells in the peripheral blood was significantly low in STAP-2 Tg recipients on day 60 (WT vs STAP-2 Tg; 44.0 /μL vs 18.2 /μL; p<0.05). In this study, we show that STAPs in reconstituted lymphocytes after allo-HSCT regulate the pathogenesis of GVHD. Our results suggest that STAP activation in lymphocytes during immune reconstitution accelerates gut and thymic GVHD. Severe thymic damage induced by STAP overexpression might contribute to impairment of immune tolerance such as a decreased number of Treg cells as well as dysfunction of thymic negative selection of host-reactive T cells after allo-HSCT, which is involved in persistence of GVHD. Future study should further elucidate the detailed molecular mechanisms involved. Disclosures Ichii: Celgene K.K.: Speakers Bureau; Kowa Pharmaceutical Co.,LTD.: Speakers Bureau; Novartis Pharma K.K.: Speakers Bureau. Shibayama:Takeda Pharmaceutical Co.,LTD.: Honoraria, Research Funding; Mundipharma K.K.: Honoraria, Research Funding; Jansen Pharmaceutical K.K: Honoraria; Ono Pharmaceutical Co.,LTD: Honoraria, Research Funding; Fujimoto Pharmaceutical: Honoraria, Research Funding; Novartis Pharma K.K.: Honoraria, Research Funding; Bristol-Meyer Squibb K.K: Honoraria, Research Funding; Celgene K.K.: Honoraria, Research Funding. Oritani:Novartis Pharma: Speakers Bureau. Kanakura:Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding.

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