B-ALL患者接受CAR-T免疫治疗后外周血炎症因子水平与细胞因子释放综合征的相关性分析

Correlation analysis between levels of inflammatory cytokine in peripheral blood and cytokine release syndrome in patients with B-ALL after CAR-T immunotherapy

目的探讨急性B淋巴细胞白血病(B-ALL)患者接受嵌合抗原受体T细胞(CAR-T)免疫治疗后,患者外周血炎症因子水平与细胞因子释放综合征(CRS)的相关性。方法选择2016年4月1日至2018年9月30日于徐州医科大学附属医院血液科接受CAR-T免疫治疗,并且相关临床资料完整的38例B-ALL患者为研究对象。其中,男性患者为21例,女性为17例;中位年龄为16岁(8~35岁)。所有患者于CAR-T静脉输注前,接受FC(氟达拉滨联合环磷酰胺)预处理方案。患者均接受人源化CD19 CAR-T(hCART19s)治疗,并且静脉输注的CAR-T数量均为1×106/kg。采用回顾性分析方法收集患者的相关临床资料、实验室及辅助检查结果。记录患者CAR-T静脉输注后d0~30的外周血铁蛋白、C反应蛋白(CRP)及白细胞介素(IL)-6检测结果的峰值。根据患者CAR-T静脉输注后d0~30的临床表现及相关检查结果,对患者的CRS进行诊断、分级。患者CRS分级与外周血铁蛋白、CRP及IL-6峰值的相关性分析,采用Spearman秩相关性分析。发生1~2级与3~5级CRS患者的外周血铁蛋白、CRP及IL-6水平比较,采用Mann-Whitney U检验。本研究遵循的程序符合徐州医科大学附属医院伦理委员会所制定的伦理学标准,得到该委员会批准(批准文号:XYFY2016-KL002-01),并且与所有受试者或其监护人签署临床研究知情同意书。结果①本研究纳入研究的38例B-ALL患者中,34例患者接受CAR-T免疫治疗后发生CRS,CRS发生率为89.5%(34/38)。其中,发生1~2级CRS的B-ALL患者为24例(63.2%),3~5级CRS为10例(26.3%)。发生CRS的B-ALL患者的临床表现主要为发热,低血压,肝、肾功能损害,凝血功能异常,中枢神经系统不良反应等。② 34例发生CRS的B-ALL患者的CRS严重程度分级与其外周血铁蛋白、CRP及IL-6峰值呈正相关关系(rs=0.779,P<0.001;rs=0.673,P<0.001;rs=0.612,P<0.001)。③ 10例发生3~5级CRS患者的外周血铁蛋白、CRP及IL-6中位峰值分别为33 080 ng/mL(2 352~69 614 ng/mL),200.0 mg/L(151.4~203.5 mg/L),799.5 pg/mL(220.9~1 677.5 pg/mL),分别高于24例发生1~2级CRS患者的1 979 ng/mL(1 133~2 147 ng/mL),86.1 mg/L(33.8~136.6 mg/L),70.7 pg/mL(18.8~265.2 pg/mL),并且差异均有统计学意义(U=210.000,P<0.001;U=92.000,P=0.005;U=201.000,P=0.001)。结论B-ALL患者接受CAR-T免疫治疗后,CRS发生率较高。患者的CRS严重程度与外周血铁蛋白、CRP及IL-6水平相关,CRS严重程度分级高的患者,其外周血铁蛋白、CRP及IL-6水平较严重程度低者显著升高。B-ALL患者接受CAR-T治疗后,需定期监测外周血铁蛋白、CRP及IL-6,当以上炎症因子水平升高时,需警惕严重CRS的发生。

Objective To explore the correlation between levels of inflammatory factor in peripheral blood and cytokine release syndrome (CRS) in patients with B cell acute lymphoblastic leukemia (B-ALL) after receiving chimeric antigen receptor T cells (CAR-T) immunotherapy. Methods From April 1, 2016 to September 30, 2018, a total of 38 patients with B-ALL who underwent CAR-T immunotherapy in the Department of Hematology, Affiliated Hospital of Xuzhou Medical University, and had complete clinical data, were selected as subjects. And 21 patients were male and 17 ones were female with median age of 16 years (8-35 years). All patients received the fludarabine combined with cyclophosphamide (FC) conditioning regimen before CAR-T immunotherapy. In this study, all of the 38 patients were treated with humanized CD19 CAR-T (hCART19s), and the total infused number of CAR-T in each patient was calculated as 1×106/kg. A retrospective research method was used to collect results of relevant clinical data, laboratory and auxiliary examination. The peak levels of ferritin, C-reactive protein (CRP) and interleukin (IL)-6 in peripheral blood were recorded on d0-30 after CAR-T immunotherapy. According to the clinical data of patients on d0-30 after CAR-T immunotherapy, the CRS of the patients was diagnosed and graded. Correlation analysis between CRS grades and peak levels of ferritin, CRP and IL-6 in peripheral blood was performed using Spearman rank correlation analysis. The Mann-Whitney U test was used to compare the peak levels of ferritin, CRP and IL-6 in peripheral blood between patients with grade 1-2 CRS and grade 3-5 CRS. The procedure followed in this study was in accordance with the ethical standards established by the Human Experimental Committee of the Affiliated Hospital of Xuzhou Medical University, and was approved by the committee (Approval No. XYFY2016-KL002-01). All subjects or their guardians signed an informed consent for this clinical research. Results ① Among the 38 patients with B-ALL in this study, there were 34 patients who developed CRS after CAR-T immunotherapy, and the incidence rate of CRS was 89.5%(34/38). There were 24 patients (63.2%) developed grade 1-2 CRS, and 10 cases (26.3%) developed grade 3-5 CRS. The main clinical manifestations of patients with CRS were fever, hypotension, liver or kidney dysfunction, coagulation abnormalities, central nervous system adverse reactions, etc..② The CRS grades of patients with B-ALL after CAR-T immunotherapy were positively correlated with peak levels of ferritin, CRP and IL-6 levels in peripheral blood (rs=0.779, P<0.001;rs=0.673, P<0.001;rs=0.612, P<0.001).③ The median peak levels of peripheral blood ferritin, CRP and IL-6 in patients with grade 3-5 CRS were 33 080 ng/mL (2 352-69 614 ng/mL), 200.0 mg/L (151.4-203.5 mg/L) and 799.5 pg/mL (220.9-1 677.5 pg/mL) respectively, which were higher than those of 1 979 ng/mL (1 133-2 147 ng/mL), 86.1 mg/L (33.8-136.6 mg/L) and 70.7 pg/mL (18.8-265.2 pg/mL) in patients with grade 1-2 CRS, and the differences were statistically significant (U=210.000, P<0.001;U=192.000, P=0.005;U=201.000, P=0.001). Conclusions The incidence rate of CRS was high in patients with B-ALL after CAR-T immunotherapy. The severity of CRS was correlated with levels of ferritin, CRP and IL-6 in peripheral blood, and the levels of ferritin, CRP and IL-6 in peripheral blood were significant elevated in patients with severe CRS. Patients with B-ALL need to regularly monitor ferritin, CRP and IL-6 in peripheral blood after CAR-T immunotherapy. When the above inflammatory factors are elevated, it is necessary to be alert to the occurrence of severe CRS.