T Cell Reconstitution in First 200 Days Post Transplantation Predicts Long Term Survival in Allogeneic Hematopoetic Progenitor Cell Transplantation (HPCT).

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 3224-3224 ◽  
Author(s):  
Laura Vann ◽  
Milcah Larks ◽  
Christopher Flowers ◽  
Sagar Lonial ◽  
Jonathan Kaufman ◽  
...  
Keyword(s):  
T Cells ◽  
T Cell ◽  
High Risk ◽  
Immune Cells ◽  
Conditioning Regimen ◽  
Low Risk ◽  
Myeloablative Conditioning ◽  
Post Transplant ◽  
Risk Patients ◽  
Study Population

Abstract Background: Successful reconstitution of cellular immunity following allogeneic HPCT reduces the risk of relapse and confers protection against opportunistic infections. We performed an IRB-approved retrospective analysis of patients who underwent allogeneic HPCT and in whom the content of immune cells were measured in the graft and in post-transplant blood samples. Methods: The study population consisted of 122 patients with hematologic disorders (71 acute leukemia; 14 chronic leukemia; 18 lymphoma, 12 MDS; 3 aplastic anemia; and 4 other) who underwent HPCT with a non-T cell depleted graft from an HLA matched related (73) or unrelated (49) donor. 47 patients had low risk disease (AA, ALL CR1, AML CR1, CML CP1), while 75 had high risk disease (all others). The conditioning regimen was non-myeloablative in 38 (31%), included ATG in 18 (15%), and included TBI in 54 (44%). Peripheral blood was drawn at a median of 101 days post-HPCT and analyzed for T-cell subsets, B-cells, NK cells, and dendritic cells. Subjects were divided into three strata based upon the maximal value for the content of each cell subset in the blood. Univariate and multi-variable stepwise logistic regression analyses were performed to test the association of pre-transplant clinical factors, the cells in the graft, and the numbers of immune cells in the blood post-transplant with overall survival. Results: The estimated three-year survival for all subjects was 53%, with death in 49/122 patients (40%) due to progressive disease (37%), infection (29%), GVHD (20%), and other causes (14%). Univariate factors associated with death included high risk, age, the use of reduced intensity conditioning regimen, the use of TBI, the use of ATG during conditioning and the measurement of lower numbers of total T-cells, CD4+ T-cells, CD8+ T-cells, γδ T-cells, DC1 and DC2 in the peripheral blood during the first 200 days post-transplant. A multi-variable Cox model identified non-myeloablative conditioning (HR 2.2, 95% CI 1.2–3.9), TBI (HR 1.9, 95% CI 1.1–3.3), transplant risk strata (HR 1.9, 95% CI 1.0–3.6), and a blood CD3+ T-cell count of less than 600 cells/mcL (HR 1.8, 95% CI 1.2–2.5) as independent risk factors for post-transplant death. The presence of acute GVHD (all grades) or graft constituents was not significantly associated with survival. Limiting the study population to those subjects who survived at least 100 days showed that blood CD3+ T-cells, non-myeloablative conditioning, the use of TBI remained significantly associated with survival. Conclusions: Higher CD3+ counts in the early post-transplant period predict better survival. Patients who fail to achieve a blood CD3+ T-cell count of >600/mcL in the first 200 days post-transplant may be appropriate subjects for adoptive cellular immunotherapy. Low Risk Patients Low Risk Patients High Risk Patients High Risk Patients

scholarly journals A Phase II Study of Decitabine Followed By Allogeneic Hematopoietic Stem Cell Transplantation in High-Risk Patients with Myeloid Malignancies

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 2107-2107
Author(s):  
Christopher R. D'Angelo ◽  
Aric C. Hall ◽  
Kyungmann Kim ◽  
Ryan J. Mattison ◽  
Walter L. Longo ◽  
...  
Keyword(s):  
Stem Cell ◽  
High Risk ◽  
Hematopoietic Stem Cell Transplantation ◽  
Stem Cell Transplantation ◽  
Chronic Gvhd ◽  
Infectious Complications ◽  
Myeloablative Conditioning ◽  
Hematopoietic Stem ◽  
Post Transplant ◽  
Risk Patients

Abstract Introduction: Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the only curative therapy for myelodysplastic syndrome (MDS) and high-risk acute myeloid leukemia (AML). Patients with high-risk disease have a markedly increased risk of relapse and death following transplant (Armand et al, Blood, 2014). Those who remain disease-free are at risk of severe morbidity from graft-versus- host-disease (GvHD). These issues highlight the importance of improved allo-HSCT platforms designed to reduce relapse rate without increasing risk of GvHD. Decitabine has minimal non-hematologic toxicity and proven efficacy in myeloid diseases (Blum et al, PNAS, 2010). Use of post-transplant cyclophosphamide has demonstrated improved rates of GvHD following allo-HSCT using haplo-identical donors (Bashey et al, JCO, 2013). No studies have reported on outcomes in patients undergoing decitabine immediately prior to transplantation followed by post-transplant cyclophosphamide (PTCy). We hypothesized that the combination of decitabine induction prior to transplant and PTCy would be safe and result in improved disease control with low rates of GVHD, translating into improved survival in a high-risk transplant cohort. Methods In this single-arm, single institution trial, eligible patients received 10 days of IV decitabine at 20mg/m2 no sooner than 24 days and no later than 17 days prior to conditioning. Myeloablative conditioning included fludarabine (50mg/m2 day-5-2), busulfan (IV 3.2mg/kg/day -5-2), and 4 Gy total body irradiation on day -1. Patients above age 65 received a 25% busulfan dose reduction. Patients received a fully or partially matched related bone marrow graft on day 0. GvHD prophylaxis included 50mg/kg of IV cyclophosphamide on day +3-4. Patients with fully matched donors received only PTCy while those with partially matched donors also received mycophenolate mofetil through day +35 and tacrolimus through day +180. Results We enrolled 20 patients, fifteen patients with AML and 5 with MDS. The cohort had a median age of 64 (29-73) and was predominantly male (14/20, 70%). Eight (40%) patients scored as high risk by the HSCT comorbidity index. Eighteen patients (90%) had a high or very high-risk score by the refined disease risk index. All patients received decitabine and 18/20 (90%) underwent transplantation; 2 patients did not receive a transplant due to infectious complications. The majority of patients received a haplo-identical graft (13/18, 72%), and the remaining 5 received a matched related graft. Outcomes are reported in table 2 and figure 1. There were no engraftment failures. Five patients, 3 MDS and 2 AML, are long-term survivors with median follow-up over 3 years. One patient developed donor derived MDS and required a second transplant. Most transplanted patients (13/18, 72%) survived to day 100 with a median post-transplant survival of 138 days. There were 15 deaths on study with the majority due to underlying disease. Six patients (6/20, 30%) died of infectious complications or did not receive a transplant due to infection. Incidence of grade 3-4 acute GvHD was low among those surviving at least 40 days from transplant (3/17, 17%). There were also low rates of chronic GvHD among the 12 patients alive without ongoing GvHD at day 100 (2/12, 17%). Conclusions Decitabine induction followed by myeloablative conditioning in this high-risk population resulted in a high treatment related mortality of 40%. Still, outcomes fell into an expected range for high-risk myeloid disease in an elderly and comorbid population. Based on expected outcomes for high-risk patients from the literature (Armand et al, Blood, 2014), decitabine did not markedly improve overall survival outcomes, recognizing that no direct comparisons are available in our limited study population. Decitabine may increase the risk of peri-transplant infections by contributing to a cumulative immunologic insult combined with disease-related immunosuppression and transplant-related toxicity, highlighting the importance of strict vigilance for infections within this setting. Diligent monitoring may improve infectious outcomes as shown in the second half of the cohort; only two out of the latter 10 patients on protocol died of treatment related complications. There were no cases of engraftment failure. Rates of acute and chronic GvHD using a PTCy platform were low and support other studies reporting this benefit. Disclosures No relevant conflicts of interest to declare.

Hematopoietic Stem Cell Transplantation (HSCT) from Alternative Donors for Acute Leukemia at High-Risk of Relapse. The Haploidentical Option.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 441-441
Author(s):  
Franco Aversa ◽  
Antonio Tabilio ◽  
Adelmo Terenzi ◽  
Stelvio Ballanti ◽  
Alessandra Carotti ◽  
...  
Keyword(s):  
T Cell ◽  
High Risk ◽  
Acute Leukemia ◽  
Cumulative Incidence ◽  
Acute Gvhd ◽  
Conditioning Regimen ◽  
Hematopoietic Stem ◽  
Prognostic Features ◽  
Post Transplant ◽  
Leukemia Relapse

Abstract Despite advances in chemotherapy for acute leukemia, survival is poor when patients have unfavourable prognostic features at diagnosis, when they do not achieve CR after the first induction cycle and when they are in second or later remission. In these circumstances an allogeneic HSCT is preferred. The chance of finding a matched unrelated donor depends on the HLA diversity and although molecular analysis achieves closer matches it reduces the probability of finding a donor. Furthermore, many patients relapse while waiting for transplant. Transplantation of HSCs from a one-haplotype mismatched family member offers an immediate source of HSCs to almost all leukemia patients who urgently need an allogeneic transplantation because of the high-risk of leukemia relapse and who do not have a matched, either related or unrelated, avaible donor. Over the past decade, our group has shown the two major obstacles to mismatched transplants, that is severe acute GVHD in T-cell-replete transplants and graft rejection in T-cell-depleted transplants, can be overcome by infusing a megadose of extensively T-cell-depleted HSCs after an immuno-myelo-ablative conditioning regimen. Since our first reports (Aversa et al. Blood 1994 and NEJM 1998), the main modifications to our original approach were: a) in October 1995, fludarabine was substituted for cyclophosphamide in our TBI-based conditioning regimen; b) peripheral blood cells were positively selected by using initially the Ceprate device and then, since January 1999, the Clinimacs instrument which ensures a 4.5 log T-cell depletion in a one-step procedure with no E-rosetting; c) in the 138 patients transplanted since January 1999 post-transplant G-CSF administration was stopped so as to improve immune recovery. The patient population included 90 AML and 48 ALL, median age 28 years (range 9–62), 40 (29%) in bad-risk CR I, 43 (31%) in second or later CR and 55 (40%) in relapse at transplant. Primary full-donor engraftment was achieved in 125/134 evaluable patients (93%); 8 patients engrafted after second transplants. Overall engraftment was achieved in 133 patients (96%). Without any post-transplant immunosuppressive prophylaxis, grade II-IV acute GvHD occurred in 7/133 evaluable patients and 5/106 developed chronic GvHD. Cumulative incidence (C.I. 95%) of non-leukemia mortality was 36% (19%–53%) and 40% (19%–66%) for patients who were respectively in CR or in relapse at transplant. 38/51 deaths were infection-related. Disease status was the major risk factor for relapse and EFS. Cumulative incidence of leukemia relapse was 27% (12%–45%) and 60% (30%–80%), p=0.006, for ALL patients in CR and relapse respectively; 17% (8%–29%) and 46% (29%–61%), p=0.0001, for AML in CR and relapse respectively. ALL and AML patients transplanted in relapse have, respectively, a 6% and 13% probability of surviving event-free. For those transplanted in remission, EFS is respectively 38% and 50% for ALL and AML patients in any CR at transplant. These results indicate the mismatched transplant should be offered to high-risk acute leukemia patients without a HLA-identical donor not as a last resort, but as a viable option in the early stages of the disease.

Cardiac Complications Following Allogeneic Bone Marrow Transplantation: Evaluation of Risk Factors, Outcomes and Enhanced Screening for At Risk Populations.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 3070-3070
Author(s):  
Michael Henry ◽  
Rong Guo ◽  
Mala Parthasarathy ◽  
John Lopez ◽  
Patrick Stiff
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
High Risk ◽  
Organ Transplant ◽  
Solid Organ Transplant ◽  
Low Risk ◽  
Solid Organ ◽  
Cardiac Events ◽  
Post Transplant ◽  
Risk Patients

Abstract Abstract 3070 Life-threatening cardiac events following allogeneic bone marrow transplants (BMT) are not uncommon at 5–12.5% of patients. While BMT programs perform screening EKGs and ejection fraction measurements, solid organ transplant centers follow a risk stratification screening algorithm to assess for coronary artery disease (CAD) which includes stress tests and as indicated, angiography in those with 2 or more risk factors. It is currently unknown whether this algorithm should be applied in the BMT setting. Methods: We performed a retrospective review of 296 patients who underwent allogeneic BMT at Loyola University Medical Center 2007–2011, to assess cardiac events using the solid organ transplant advanced screening criteria: age over 60 or over 40 with peripheral vascular disease or diabetes and then divided patients into low risk (one CV risk factor) and high risk groups (greater than one CV risk factor). Risk factors included age, hypertension, diabetes, smoking, family history of CAD, and obesity according to the Framingham risk assessment score for CAD. Cardiac events during the first year post-transplant were recorded including CHF, myocardial infarction (MI), and symptomatic arrhythmias. One hundred day and 1-year Kaplan-Meier survival for high and low risk patients were determined and curves compared by log-rank tests. A multivariate analysis of the various prognostic factors was performed using the Cox regression model. Results: Of the 296 total allografts, 116 patients (39%) fit the solid organ transplant criteria for advanced screening; 62% were male (n = 72) and the mean age was 60.6 (range 40–72). Graft source was evenly distributed between siblings (42%), unrelated (39%) and cord blood (28%). Acute myeloid leukemia was the most common indication for BMT at 40%, followed by MDS (21%), non-Hodgkin lymphoma (16%), and CLL (10%). Of the 116, 21 were considered low risk (1 risk factor), while 95 were high risk (2+ risk factors). Low risk and high risk groups did not differ in disease type (p = 0.43), graft source (p = 0.81), or graft type (p = 0.54). Surprisingly, both high and low risk patients had a similar incidence of cardiac events of 36% and 48%, respectively. This correlated to comparable 100-day and 1 year survival rates. To determine the importance of cardiac complications on outcome and whether there were other risk factors for complications we analyzed those with a complication. Forty-four cardiac events occurred in the first year after transplant in 38 (33%) patients. Cardiac events included arrhythmias (n = 33), new onset CHF (n = 6), and MI (n = 5). Median time to event was 16 days post-transplant. Symptomatic arrhythmias included atrial fibrillation (n = 27, 82%), supraventricular tachycardia (n = 5, 15%) and sustained ventricular tachycardia (n =1, 3%). Median age for patients with cardiac events was 62.7 years, compared to 59.6 for patients who experienced no cardiac events (hazard ratio estimate: 1.076; p = 0.02). As compared to patients with no post-transplant cardiac events, both the 100 day and 1 year survival rates of patients with cardiac events were lower with one year survival of 21% vs. 63% (p < 0.0001). Evaluating risk factors, 3 were significant: donor source with MUD donors the highest hazard (p = 0.04); age, with cardiac events occurring at a rate twice as high in patients greater than age 60 (n = 27, 36.5% vs. n = 6, 19.4%), and with all five cases of myocardial infarction and 5/6 new CHF diagnoses occurring in patients aged 60 or greater; and patients with a history of atrial fibrillation demonstrated a higher probability of developing a cardiac event post-transplant (p = 0.02). Conclusions: In this analysis, we saw a much higher incidence of post-BMT cardiac events (33%) than previously reported, although we focused only on at risk patients using the solid organ screening algorithm (pts > 40 with significant risk factors or all pts > 60). As mortality rates at 100 day and 1 year are higher for patients who suffer a post-BMT cardiac event, and only graft source, age and prior atrial fibrillation marked patients at a very high risk, this data indicates that it is appropriate to investigate prospectively the solid organ transplant algorithm in all allogeneic BMT patients > age 40, with low cardiac risk or any patient > 60 with stress tests and as indicated, cardiac catheterization. Whether this will decrease events and thereby improve survival remains to be determined by prospective studies. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Oncogenetic Risk Classification Based on NOTCH1/FBXW7/RAS/PTEN Mutation Profiles Improves Outcome Prediction in Pediatric T-Cell Acute Lymphoblastic Leukemia, Treated According the Fralle 2000 T Guidelines

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1083-1083 ◽  
Author(s):  
Arnaud Petit ◽  
Amélie Trinquand ◽  
Sylvie Chevret ◽  
Paola Fabiola Ballerini ◽  
Jean-Michel Cayuela ◽  
...  
Keyword(s):  
Acute Lymphoblastic Leukemia ◽  
T Cell ◽  
High Risk ◽  
Lymphoblastic Leukemia ◽  
Low Risk ◽  
Study Cohort ◽  
Risk Patients ◽  
Cell Acute Lymphoblastic Leukemia ◽  
Wbc Count ◽  
Risk Of Relapse

Abstract Background: Risk stratification in childhood T-cell acute lymphoblastic leukemia (T-ALL) is crucial to drive treatment decisions. Since patients with induction failure or relapse are often refractory to further treatment, identifying high risk patients up-front will allow improved treatment. While minimal residual disease (MRD) is the strongest prognosis risk factor used after complete remission (CR), NOTCH1/FBXW7 (N/F) and RAS/PTEN (R/P) mutation profiles at diagnosis have recently been identified to predict outcome in adult T-ALL. Objective: to test whether an oncogenetic classifier using N/F and R/P mutations could improve the detection of children with T-ALL at risk of relapse. Methods: 405 patients with T-ALL aged from 1 to 14 years were treated according to FRALLE T guidelines (FRALLE Study group) between 2000 and 2010. Among them, 220 patients, for whom biological material at diagnosis was available, were tested retrospectively for N/F and R/P mutations. These study cohort patients were representative of overall FRALLE 2000 T-ALLs. CR was achieved in 213 patients. MRD (IgH-TCR markers) tested at CR (day 35) was available for 191 patients. MRD was <10-4 for 114 patients (60%) and ≥10-4 for 77 patients. Patients with N/F mutation and R/P germline (GL) were defined as oncogenetic low risk (LoR), while N/F GL and R/P GL or mutation and N/F mutation and R/P mutation were defined as high risk (HiR). Results: 111 patients were classified as LoR and 109 as HiR. Five-year-CIR and DFS were respectively 35.5% (95% CI, 26.7-44.3) and 59% (95%CI, 50.2-69.6) for HiR versus 13% (95% CI, 6.8-19.2) and 86.8% (80.5-93.5) for the LoR group (Figures A and B). HiR patients were significantly associated with MRD ≥ 10-4 (p=0.0004) and higher risk of relapse (p=0.00002). Among patients with MRD ≥ 10-4, HiR feature worsened the risk of relapse: 5-year-CIR and DFS were respectively 42.8% (95% CI, 28.9-56.7) and 71.1% (95%CI, 56.0-90.2) in HiR versus 28.9% (95% CI, 11.7-46.1) and 50.9% (95%CI, 38.4-67.6) in the LoR group. Among patients with MRD <10-4, 5-year-CIR and DFS were respectively 28.9 % (95% CI, 15.0-42.8) and 71.0% (95%CI, 58.4-86.3) in HiR group versus 4.4% (95% CI, 0-9.2) and 95.5% (95%CI, 90.7-1.00) in LoR group (Figures C and D). As such, the classifier allowed identification of 63% of very low risk patients amongst the MRD<10-4 population. Prognostic values of new oncogenetic risk factors were then analyzed with conventional factors. By univariate analysis, factors identified to predict relapse were male gender (p=0.036), WBC count ≥ 200 G/L (p=0.023), chemoresistance at day 21 (p=0.007), MRD ≥10-4 (p=0.0006) and oncogenetic HiR (p<0.0001). A multivariable cox model including these variables selected the classifier together with WBC count, day 21 chemo-sensitivity and MRD. Based on a stepwise selection procedure, the three most discriminating variables were classifier, WBC count and MRD. The cause specific Hazard Ratio (HR) was 3.22 (95% CI, 1.64-6.28) for oncogenetic HiR versus LoR (p=0.0006), 2.30 (95% CI, 1.26-4.20) for MRD≥10-4 versus MRD<10-4(p=0.0070) and 1.85 (95% CI, 1.01-3.37) for WBC≥200G/L versus <200 G/L (p=0.0456). Based on these three parameters, 8 subsets of patients were defined according to the estimated 5-year CIR. The 58 patients (30%) associating WBC count < 200G/L, classifier LoR and MRD<10-4 were at very low risk of relapse, with a 5-y-CIR of 1.7%. Patients harboring at least one of: WBC count ≥200G/L, classifier HiR or MRD>10-4, demonstrated an increasing CIR, up to 45.8% if all three were associated. Conclusion: in childhood T-ALL, oncogenetic classification using N/F and R/P mutation profiles is an independent predictor of relapse. When combined with MRD and WBC count ≥200 G/L, it significantly improved relapse prediction, particularly amongst the 60% of T-ALLs with MRD <10-4 at day 35. Appropriate integrating these 3 factors, will help optimize treatment. Figure Figure. Disclosures No relevant conflicts of interest to declare.

scholarly journals Use of Ex Vivo Graft Manipulation and Posttransplant Cyclophosphamide Result in Low GvHD Rates and Acceptable Engraftment after RIC Regimens in Pediatric Mismatched SCT

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3255-3255
Author(s):  
Peter Lang ◽  
Michaela Döring ◽  
Anne-Marie Lang ◽  
Patrick Schlegel ◽  
Christian M. Seitz ◽  
...  
Keyword(s):  
T Cells ◽  
T Cell ◽  
Immune Suppression ◽  
Pediatric Patients ◽  
Ex Vivo ◽  
Conditioning Regimen ◽  
Post Transplant ◽  
Donor T Cells ◽  
Organ Dysfunctions

Introduction: There are currently two strategies to prevent Graft-versus-Host Diseases (GvHD) mainly applied in haploidentical transplantation. One is ex-vivo T-cell depletion of TcRa/b T-cells and the other is the T-replete approach, in which the donor T-cells remain in the graft and are tolerized in vivo by post-transplant cyclophosphamide (pCy). The ex-vivo depletion strategy does not require post-transplant immune suppression for GvHD prevention, whereas T-replete transplants require intensive immune suppression. A major obstacle for engraftment is the persistence of patients' T-cells despite intensive and myeloablative condition regimens, thus probably leading to rejection of the graft. We hypothesized that both methods could be combined in a setting of Reduced Conditioning setting (RIC). The ex-vivo T-cell depletion would allow to omit post-transplant immunosuppression and the pCy given at day +3 and +4 could induce in-vivo tolerance of the residual patients' T-cells not eliminated by RIC. Therefore, we applied this strategy in patients who were not eligible based on their poor clinical condition and who were considered to endure only a very reduced conditioning regimen. Results: We report on a cohort of 6 pediatric patients who were not eligible for myeloablative condition regimens due to preexisting organ dysfunctions (lungs, gut or liver) but were in urgent need of an SCT from matched unrelated (n=2) or haploidentical family donors (n=4). Diagnoses were: immune deficiencies (n =4; CARMIL 2, STAT 1, ICF 2, 1 not classified), relapsed metastatic ependymoma, refractory Burkitt´s lymphoma. All patients received a non-myeloablative conditioning regimen (ATG (Thymoglobin) 2mg/kg d-9 to d-7, fludarabine 30mg/m² d-6 to d-2, TBI 4Gy d-1, cyclophosphamide 50mg/kg d+3, d+4; adapted from Aversa, Reisner et al. Blood Adv. 2017). One patient additionally received thiotepa 2x5mg/kg on d-2. The CliniMACS® device was used for TCRab/CD19 depletion of peripheral stem cells; a median number of 14x10E6 CD34+ cells/kg bw with 6.4x10E3/kg bw residual TCRa/b T-cells was infused without any further posttransplant immune suppression. Four patients received a single add back of CD45 RA depleted donor T-cells at d+7. Dosages of 1x10E5/kg, 1x10E6/kg or 5x10E6/kg were administered. Two patients received an additional T-cell depleted stem cell boost after application of pCy Engraftment occurred in 4/6 patients; 2 patients rejected their haploidentical grafts and showed complete autologous reconstitution. Median time to reach ANC>500 was 19 days (range 15-23). Four patients had no signs of GvHD; 1 patient had grade I; the patient who had received the highest dose of CD45RA depleted DLI developed grade III but could be treated successfully. No cGvHD occurred. Immune recovery was rapid. Median numbers of CD3+ T-cells, CD3/CD4+ T-cells, CD19+ B cells and CD56+ NK cells at d30 and d100 were 120/µl, 9/µl, 0/µl, 140/µl and 205/µl, 60/µl, 67/µl and 206/µl, respectively. 3 patients are alive and well with a median follow up of 824 days (43-1100). Last observed donor chimerisms were 95-100%. Causes of death in 3 other patients were: MAS/sepsis (STAT 1 deficiency, d 264) and progression in both patients with malignancies (d282 and d73). The patient with relapsed ependymoma showed a transient tumor regression for 3 months posttransplant whereas the patient with refractory Burkitt´s lymphoma had only a short response for 4 weeks. Conclusions: The combination of TCRa/b depletion and pCy allowed to use a very reduced conditioning regimen which could be administered in pediatric patients even with preexisting significant organ dysfunctions without severe side effects. GvHD could be effectively prevented (except in one patient who received a high number of DLI) together with an acceptable engraftment rate provided by post cy. Thus, this method might offer the possibility to establish a donor-derived hematopoiesis without using pharmacological myeloablation and with minimal toxicity and might be the basis for future strategies to further reduce the conditioning regimen, especially for patients with non-malignant diseases. Disclosures No relevant conflicts of interest to declare.

CMV-Seropositive Patients Allografted with a CMV-Seronegative Donor Show Delayed or Missing CMV-Specific T-Cell Immune Response and Are at Higher Risk for CMV-Viremia and CMV-Disease.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 3249-3249
Author(s):  
Susanne Ganepola ◽  
Chiara Gentilini ◽  
Urte Hilbers ◽  
Goetz Hartung ◽  
Thoralf Lange ◽  
...  
Keyword(s):  
T Cells ◽  
T Cell ◽  
High Risk ◽  
Cell Response ◽  
T Cell Response ◽  
First Year ◽  
Seronegative Donor ◽  
High Risk Patients ◽  
Risk Patients ◽  
Cmv Disease

Abstract The human cytomegalovirus (CMV) is an important cause for mortality and morbidity after allogeneic stem cell transplantation (allo SCT) especially in patients without a CMV-specific T cell response. CMV seropositive patients allografted with a CMV seronegative donor do not rise up specific CMV-T cell immunity posttransplant and are therefore at great risk for CMV viremia and disease. In a prospective manner, we analyzed blood samples of 38 HLA-A2+ patients with different haematological malignancies for CMV specific T cells. Methods: Frequency of T cells with reactivity against the pp65-peptide (NLVPMVATV) was assessed by ELISPOT assay in 38 patients at defined time points after allo SCT. In patients with high CMV specific T cell frequencies, the T cell phenotype was determined by flow cytometry. Surveillance of CMV viremia was carried out by routine PCR-technique or pp65 Ag staining. Results: In high-risk patients (donor-/recipient+) viremia was observed in 7/9 patients, 3/7 developed clinical severe CMV-disease. In this group, only one patient presented a weak CMV-specific T cell response in the first year after transplantation, although CMV-specific T cells were demonstrated in 5/9 patients before transplantation. In contrast, 64% (11/17) of the CMV seropositive patients having had a CMV seropositive donor showed CMV-specific T cells around day 30. Their T cell frequencies remained stable at a relative high level during the whole time of our investigation period and no CMV disease was observed. CMV seronegative patients allografted with either a CMV seronegative or seropositive donor also remained disease-free. CMV specific T cells were detectable in 2/7 patients of the d+/r− group. FACS analysis revealed that most of the responding cells were of the activated effector phenotype CD8+/CD45RA+/HLA-DR+ with a low expression of CCR7 and CD27. Conclusion: CMV-seropositive patients receiving graft from a seronegative donor are at a high risk and therefore prone for CMV-viremia and -disease. The development of CMV-specific T cells i.e. immune reconstitution in high risk patients remains delayed or is completely missing during the first year post transplant. In contrast, seropositive recipients grafted with a seropositive donor develop a durable T cell response within 3–4 weeks and show no viremia at all. New strategies as donor vaccination and adoptive T cell transfer are warranted to prevent CMV-disease in CMV seropositive patients for whom only a seronegative donor can be found.

A Role for Regulatory Cells in Tolerance Induction in Recipients of Haploidentical Combined Non-Myeloablative Bone Marrow and Kidney Transplantation?.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 3255-3255
Author(s):  
Giovanna Andreola ◽  
Meredith Chittenden ◽  
Juanita Shaffer ◽  
A. Benedict Cosimi ◽  
Tatsuo Kawai ◽  
...  
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
T Cell ◽  
Conditioning Regimen ◽  
Tolerance Induction ◽  
In Vitro Assays ◽  
Mixed Chimerism ◽  
Post Transplant ◽  
Hla Dr

Abstract Following an in vivo T cell depleting non-myeloablative conditioning regimen, 5 patients, aged 22–49, received combined kidney and bone marrow transplantation from a haploidentical related donor. Rituximab was included in the conditioning for patients 4 and 5. All patients developed initial mixed chimerism but lost it by day 21; no patient developed GVHD. Four patients discontinued immunosuppression from 240 to 422 days after BMT and have remained off immunosuppression for 9 to 52 months with no evidence of allograft rejection. Flow cytometry was used to assess lymphocyte subsets recovering after transplant. CD3 counts recovered slowly, exceeding 500 cells/μl at days +271, +365, +640 and +450. While memory CD45RO+ cells were most prevalent among CD4+ cells, naïve-type CD4+CD45RA+ cells, presumably arising from the recipient thymus, ranged from 8% to 56% at the time when total CD4 counts recovered to >100 cells/μl (days +165, +21, +352, +240). Notably, a very high proportion of initially recovering T cells were CD3+CD4+ expressing CD25 in all patients as early as day 7 and persisted over 1 year in 2 patients. At approximately day +120 and +365, we further characterized these cells for CD127, FOXP3, CD45RO, CD45RA, HLA-DR and CD62L expression. At Day +120, all 4 patients showed increased frequencies (10.7±4.6%) of CD25+CD127-FOXP3+ regulatory T cells (Treg) within the CD4 population compared to healthy subjects (3.8±0.4%). Expression of CD45RO, CD45RA, CD62L and HLA-DR was variable. By 1 year post-transplant, frequencies of Treg had decreased to levels similar to those in normal subjects. In vitro assays for CD8 and CD4 T cell-mediated alloreactivity (CML/MLR) showed development of long-lasting donor-specific unresponsiveness by 3 months after transplant in Patients 2, 4 and 5, and by 9 months in Patient 1. Responses to 3rd party recovered in all patients after a period of unresponsiveness. In Patient 1, in whom anti-donor CML reactivity declined gradually to become unresponsive by 9 months, depletion of CD4+CD25+ cells revealed a residual anti-donor CML and MLR response at 1year but not at 18 months. In 2 other patients, depletion of CD4+CD25+ cells did not reveal an anti-donor response at time points analyzed from day +122 to 2 years. In patients in whom renal tubular epithelial cells (RTEC) were cultured from the donor kidney, loss of killing activity against donor RTEC was observed post-transplant. The high percentage of Treg recovering early after transplant suggests that they may play a role in initial tolerance induction. This regulatory mechanism may be followed by later deletion of donor-reactive T cells. The variable ability to detect regulation of anti-donor reactivity may reflect the strength of the initial response, as patients with weak pre-transplant anti-donor responses and rapid post-transplant development of donor unresponsiveness did not reveal anti-donor response when Treg were depleted. In addition, infiltration of Treg at the graft site, not revealed by the assays described, might be responsible for tolerance in these patients.

scholarly journals T Cell Expression and Release of Kidney Injury Molecule-1 in Response to Glucose Variations Initiates Kidney Injury in Early Diabetes

2021 ◽  
Author(s):  
Josephine M. Forbes ◽  
Domenica A. McCarthy ◽  
Andrew J. Kassianos ◽  
Tracey Baskerville ◽  
Amelia J. Fotheringham ◽  
...  
Keyword(s):  
T Cells ◽  
Type 1 Diabetes ◽  
T Cell ◽  
High Risk ◽  
Kidney Disease ◽  
Kidney Injury ◽  
Glycemic Variability ◽  
Low Risk ◽  
Kidney Injury Molecule 1

Half of the mortality in diabetes is seen in individuals <50 years of age and commonly predicted by the early onset of kidney disease (DKD). In Type 1 diabetes, increased uACR (urinary albumin-creatinine ratio) during adolescence defines this risk, but the pathological factors responsible remain unknown. We postulated that early in diabetes, glucose variations contribute to kidney injury molecule- 1 (KIM-1) release from circulating T cells, elevating uACR and DKD risk. <p>DKD risk was assigned in youth with type 1 diabetes [n=100; 20.0±2.8 yrs; M:F-54:46, HbA<sub>1C</sub>-66.1(12.3) mmol/mol; diabetes duration-10.7±5.2 yrs; BMI-24.5(5.3) kg.m<sup>-2</sup>] and 10 year historical uACR, HbA<sub>1C</sub> and random blood glucose concentrations collected retrospectively. Glucose fluctuations in the absence of diabetes were also compared to streptozotocin diabetes in <i>Apolipoprotein E-/-</i> mice. Kidney biopsies were used to examine infiltration of KIM-1 expressing T cells in DKD and compared with other chronic kidney disease.</p> <p>Individuals at high risk for DKD had persistent elevations in uACR (uACR<sub>AUC0-10yrs</sub>, 29.7±8.8 vs 4.5±0.5; <i>P</i><0.01 vs low risk) and early kidney dysfunction including ~8.3ml.min<sup>-1</sup>.1.73m<sup>-2</sup> higher estimated glomerular filtration rates (eGFR<sub>SCHWARTZ</sub>; <i>P<sub>adj</sub></i> <0.031 vs low risk) and plasma KIM-1 concentrations (~15% higher vs low risk;<i> P</i><0.034). High risk individuals had greater glycemic variability and increased peripheral blood T cell KIM-1 expression, particularly on CD8+ T cells. These findings were confirmed in a murine model of glycemic variability both in the presence and absence of diabetes. KIM-1+ T cells were also infiltrating kidney biopsies from individuals with DKD. Healthy primary human proximal tubule epithelial cells exposed to plasma from high risk youth with diabetes showed elevated collagen IV and SGLT2 expression, alleviated with KIM-1 blockade. Taken together, these studies suggest that glycemic variations confer risk for DKD in diabetes via increased CD8+ T cell production of KIM-1.<b><br> </b></p>

scholarly journals Novel Simultaneous Single Cell mRNA and Protein Expression Profiling Identifies Distinct Treg and T Effector Signatures in the Bone Marrow of MDS Patients

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 2980-2980
Author(s):  
Jessica Ann Timms ◽  
Susann Winter ◽  
Steven Hargreaves ◽  
Donal P. McLornan ◽  
Uwe Platzbecker ◽  
...  
Keyword(s):  
Bone Marrow ◽  
T Cells ◽  
High Risk ◽  
Protein Expression ◽  
Single Cell ◽  
Expression Profiling ◽  
Low Risk ◽  
Risk Patients ◽  
Activation Pathways ◽  
Cell Fractions

Background Regulatory T cells (Tregs) are a non-redundant, suppressive population of CD4+ T cells that are essential for the prevention of autoimmune diseases in humans. They may also contribute to overall immune suppression in malignancies and prevent effective immune surveillance against malignant cells. The correlation between the increased number of Tregs and higher-risk MDS has been shown before (Kordasti, Blood 2007). Expansion of effector T cells (Teff) also signifies the lower-risk disease (Kordasti, BJH, 2009). Using deep phenotyping and unbiased automated clustering we have previously identified novel populations of Tregs with distinct functional properties (Kordasti, Blood 2016), including a CD161-expressing subpopulation (Povoleri, Nature Imm, 2018). The aim of this study was to interrogate Treg and Teff subpopulations in more depth and identify transcriptomic profiles of Tregs and Teff in bone marrow (BM) and peripheral blood (PB) of MDS patients, and potential differences between PB and BM residing cells. Single-cell RNA sequencing (scRNAseq) in combination with oligonucleotide-tagged antibodies and an in-house pipeline utilizing Seurat for QC, data integration and analysis were used for this purpose. Methods PB and BM were collected from a low (del(5q)) and a high-risk (monosomy 7) MDS patient. These samples were magnetically enriched for CD4+ T cells, followed by flow sorting of Tregs (CD4+, CD25high, and CD127low) and Teff (CD4+, CD25low, and CD127high). In total, 8 cell fractions were used for downstream scRNAseq and concomitant protein expression profiling using the BD Rhapsody Single-Cell Analysis System (Becton Dickinson, CA, USA). Cell fractions were first labelled by oligo-tagged antibodies (CD95, CD45RO, CD38, CTLA-4, PD-1, HLA-DR) and a sample tag (for sample multiplexing). After labelling, all samples were combined for cartridge-based single-cell capture and molecular indexing of mRNA transcripts on magnetic barcoded beads. Following bead retrieval and on-bead cDNA synthesis, parallel targeted mRNA (259 T cell-related genes) and Abseq sequencing libraries were generated. Deep sequencing was performed using the HiSeq400 platform. Nonlinear dimensionality reduction was carried out using uniform manifold approximation and projection (UMAP), which produced UMAP layouts and heatmaps to identify populations. Tregs were further stratified according to high/low expression of the CD95 protein, CD161, and CD150 mRNA expression. The Wilcoxon Rank Sum test was used for statistics followed by Bonferroni corrections. The Gene Set Variation Analysis (GSVA) package was used for pathway enrichment analysis. Results and discussion Unbiased analysis by UMAP was able to clearly separate the high- and low-risk patients based on the Treg and Teff signature in BM, which was not the case in PB (Figure 1a and 1b). At protein level, BM Tregs from the high-risk patient had a significantly higher expression of CD95 (p = 7.23 x 10-17), CD45RO (p = 1.06 x 10-51), CTLA4 (p = 4.47 x 10-83) PD-1(p = 5.42 x 10-81), and CD38 (p = 4.16 x 10-63) (Figure 1c), suggesting a more functional Treg profile. GSVA analysis of transcriptomes showed significant changes between high- and low-risk patients, for both Tregs (102 pathways p≤0.05) and Teffs (89 pathways p≤0.05) in BM. Specifically, Tregs from high-risk MDS were more enriched with non-TCR-mediated activation pathways, including leukocyte differentiation, Jak-STAT signaling, and positive regulation of leukocyte cell-cell adhesion (Figure 1d). A deeper investigation of Tregs showed that subsets of interest, in particular the IL-17 secreting CD161+ Tregs and the hematopoietic stem cell quiescence-maintaining CD150+ Tregs (Hirata, 2018) were found in low abundance in the BM of both high- and low-risk patients; 16% and 10%; and, 1% and 7%, respectively. In summary, we have developed an analytical pipeline and provide evidence for the ability of simultaneous single-cell transcriptomics and protein expression to identify different BM-specific T cell signatures in high- versus low-risk MDS. Interestingly, Tregs from high risk MDS BM show higher expression of Treg-related proteins and are more enriched in non-TCR-specific activation pathways, which may reflect a myeloid derived inflammatory environment. Overall, these findings suggest a bone marrow-specific Treg signature in MDS, which could distinguish low- and high-risk disease. Disclosures McLornan: Jazz Pharmaceuticals: Honoraria, Speakers Bureau; Novartis: Honoraria. Platzbecker:Celgene: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria. Kordasti:Celgene: Research Funding; Novartis: Research Funding; Boston Biomed: Consultancy; API: Consultancy.

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