Incidence of ocular manifestations in patients with graft versus host disease after allogeneic stem cell transplant in Riyadh, Saudi Arabia

AIM: To evaluate the incidence and severity of ocular graft versus host disease(o GVHD) in patients who underwent allogeneic stem cell transplant(SCT) in King Abdul-Aziz Medical City, Saudi Arabia.METHODS: This is a retrospective cohort study conducted in King Abdul Aziz Medical City on patients who underwent allogeneic hematopoietic cell transplant(allo-HCT) from 2010 to 2017. The ocular examination findings including visual acuity, meibomian gland dysfunction, corneal and conjunctival staining with severity, corneal scarring, tear film meniscus and breakup time, anterior and posterior segment examination findings, intraocular pressure, treatment given, punctual plugs used or not, and follow up response were collected.RESULTS: The five years cumulative incidence of o GVHD among post-transplant patients was 56.98%(95%CI 38.6%-71.7%). The potential risk factors assessed for developing ocular manifestation were age, gender, donor’s age, donor gender mismatch CD3 and CD34 infusion, while none of the correlates were identified as statistically significant risk factors of developing ocular manifestation. However, the incidence was statistically significantly different betweenpatients diagnosed with acute myelocytic leukemia and acute lymphocytic leukemia(P=0.038). The mean latent period to develop ocular symptoms was 20.5 mo. All patients had variable degree of dry eyes. None of the patients developed any posterior segment complication.CONCLUSION: The incidence of o GVHD is low in King Abdul-Aziz Medical City. This can be attributed to the preconditioning and immunosuppressive regime.

Colonoscopy in the diagnosis of intestinal graft versus host disease and cytomegalovirus enteritis following allogeneic haematopoietic stem cell transplantation

Background Gastrointestinal graft versus host disease （GI-GVHD） and cytomegalovirus （CMV） enteritis are important complications following allogeneic haematopoietic stem cell transplantation （allo-HSCT）. We explored the role of colonoscopy in the diagnosis of GI-GVHD and CMV enteritis following alIo-HSCT to identify the endoscopic manifestations of GI-GVHD and CMV enteritis was made. Methods A retrospective analysis of the colonoscopic manifestations of GI-GVHD, CMV enteritis and GI-GVHD with concurrent CMV enteritis （GconC） and their related clinical issues. Results Forty-seven patients underwent 50 colonoscopies with diagnoses of 32 GI-GVHD, 7 CMV enteritis and 11 GconC. Both GI-GVHD and CMV enteritis had colonic mucosal lesions with various manifestations under colonoscopy. Tortoise shell like changes of the mucosa （12 of 32） and deep ulcers （2 of 7） were specific endoscopic manifestations for GI-GVHD and CMV enteritis, respectively, while mucosal oedema, erythema, congestion, erosion and shallow ulcers could not be used to differentiate GI-GVHD from CMV enteritis. GconC patients were prone to have oozing bleeding of the end ileal mucosa and typhlodicliditis. Of the biopsed specimens for GI-GVHD, CMV enteritis and GconC, 64%, 70% and 44% were taken from the rectum and sigmoid colon respectively. Conclusions Following allo-HSCT, tortoise shell like changes and deep ulcers of the colonic mucosa are characteristic changes for GI-GVHD and CMV enteritis, respectively, while the other lesions are not. Most of the GI-GVHDs and CMV enteritis cases can be diagnosed by left colon examination and tissue biopsy, but total colon examination to the terminal ileum is preferred.

PLACENTAL INTRAVENOUS IMMUNOGLOBULIN (PtIVIG) FOR TREATMENT OF CHRONIC GRAFT VERSUS HOST DISEASE (CGVHD)

Plasma immunoglobulin has been used widely in clinic for the prophylaxis and treatment of infections in patients after bone marrow transplantation(BMT).However,there are no hard data demonstrating that it can act against GVHD,

Graft versus host disease after liver transplantation:A case report

In documenting clinical experience in the diagnosis and treatment of graft versus host disease(GVHD),we retrospectively analyzed data of one case that has developed GVHD after liver transplantation.This patient exhibited fever,skin rash,and diarrhea on day 9 after liver transplantation.His liver function was normal.Skin biopsy showed scattered keratinocytes accompanied by satellite-like lymphocyte infiltration and basal cell liquefaction degeneration.After carefully analyzing the complications,we took the strategy of decreasing the dose of tacrolimus.Thereafter,the patient’s temperature decreased to normal,his skin rashes subsided,and his diarrhea was relieved.This case suggests that reducing the dosage of immunosuppressive agents can be an effective strategy for GVHD after liver transplantation.

Advances in the role of follicular T helper cells in graft versus host diseases

Graft versus host disease(GVHD)is a refractory complication of allogeneic hematopoietic stem cell transplantation for the treatment of malignant and non-malignant hematopoietic diseases.Inflammatory cascade responses and cellular immune reactions are the major factors underlying GVHD pathogenesis.Cells producing the cytokine,interleukin(IL)-21 are crucial players involved in injured tissues in GVHD patients.Besides T helper 17 cells,follicular T helper(Tfh)cells are a new source of IL-21 and play a vital role in GVHD pathogenesis.Tfh cell function is mostly regulated by T-follicular regulatory(Tfr)cells that are also located in the germinal center.This review highlights recent advances in the role of Tfh and Tfr cell function in GVHD pathogenesis.New insights are provided into the potential for clinical application in GVHD prevention and treatment.

Glucocorticoid and glycolysis inhibitors cooperatively abrogate acute graft-versus-host disease

Although glucorticosteroids(GCs)are the standard first-line therapy for acute graft-versus-host disease(a Gv HD),nearly 50%of a Gv HD patients have no response to GCs.The role of T cell metabolism in murine a Gv HD was recently reported.However,whether GCs and metabolism regulators could cooperatively suppress T cell alloreactivity and ameliorate a Gv HD remains to be elucidated.Increased glycolysis,characterized by elevated 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3(PFKFB3),and higher rates of glucose consumption and lactate production were found in Tcells from a Gv HD patients.Genetic upregulation of PFKFB3 induced T cell proliferation and differentiation into proinflammatory cells.In a humanized mouse model,PFKFB3-overexpressing or PFKFB3-silenced T cells aggravated or prevented a Gv HD,respectively.Importantly,our integrated data from patient samples in vitro,in a humanized xenogeneic murine model of a Gv HD and graft-versus-leukaemia(GVL)demonstrate that GCs combined with a glycolysis inhibitor could cooperatively reduce the alloreactivity of T cells and ameliorate a Gv HD without loss of GVL effects.Together,the current study indicated that glycolysis is critical for T cell activation and induction of human a Gv HD.Therefore,the regulation of glycolysis offers a potential pathogenesis-oriented therapeutic strategy for a Gv HD patients.GCs combined with glycolysis inhibitors promises to be a novel first-line combination therapy for a Gv HD patients.

Protective effect of human CD40-Ig fusion protein in a murine model of acute graft-versus-host disease

Abstract:Objective To investigate the protective effects of blocking CD40/CD40L interactions with human CD40-Ig fusion protein in a murine graft-versus-host disease model.Methods Human CD40 gene extracellular region was inserted into plasmid pIG1, which contains genomic human IgG1 Fc gene. A transient vector containing CD40-Fc fusion gene was transfected into COS-7 cells. The CD40-Ig fusion protein was detected through enzyme-linked immunosorbent assay (ELISA). A constitutive vector was also generated by ligating the CD40-Fc fusion gene into pcDNA3.1 and transfecting it into CHO cells. CD40-Ig was purified by protein A affinity chromatography. SDS-PAGE, Western blot and ligand binding assay were used to identify the qualities of CD40-Ig. Murine acute graft-versus-host disease (GVHD) was induced by intravenous injection of C57BL/6J (H-2b) spleen cells into sub-lethally irradiated BALB/c (H-2d) mice. Protective effects against murine graft-versus-host disease by in vivo administration of CD40-Ig were evaluated.Results Mammalian expression vectors pIG/40Ig and p3.1/40Ig were constructed as described above. Chimeric proteins were expressed in COS-7 and CHO cell culture supernatant and confirmed by ELISA and Western blot. SDS-PAGE showed that fusion proteins had a disulfide-bonded dimeric structure and existed as homodimer. Purified CD40-Ig could bind to CD40L. In vivo administration of CD40-Ig could prevent the development of GVHD and significantly prolong the mean survival time of mice with graft-versus-host disease.Conclusions These results demonstrate that CD40/CD40L interactions play an important role in the pathogenesis of graft-versus-host disease and suggest clinical potential for CD40-Ig in the prevention and treatment of human graft-versus-host disease.

Ocular manifestations and quality of life in patients after hematopoietic stem cell transplantation

AIM:To explore the relationship between ocular and systemic conditions and the impact of ocular complications on the quality of life(QOL)in patients after allogeneic hematopoietic stem cell transplantation(ALLO-HSCT).METHODS:Forty-four patients with severe hematopoietic disease were enrolled after ALLO-HSCT at our center from July 2018 to October 2020.They completed two questionnaires:the Ocular Surface Disease Index(OSDI)and the quality-of-life scale for Chinese patients with visual impairment(SQOL-DV1).Ocular conditions and systemic conditions were also assessed.RESULTS:Eye damage was correlated with total bilirubin(P=0.005),and gamma-glutamyl transferase(GGT)(P=0.021).There was no significant correlation between the overall QOL score and OSDI(P=0.8226)or SQOLDV1(P=0.9526)scores.The OSDI and the overall QOL score were not correlated with ocular conditions,including best-corrected visual acuity(BCVA),intraocular pressure,Schirmer tear test II,sodium fluorescein staining,tear film breakup time,and tear meniscus height.SQOLDV1 was correlated with BCVA(P=0.0007),sodium fluorescein staining(P=0.007),and tear film breakup time(P=0.0146).CONCLUSION:In some patients,early ocular symptoms are not evident after ALLO-HSCT,while ocular surface complications can be observed after a comprehensive ophthalmological examination.Especially for those with elevated total bilirubin or GGT,regular ophthalmic follow-up visits are essential to diagnose and treat ocular graft versus host disease(o GVHD),especially for patients with elevated total bilirubin or GGT.

Neurological complications of hematopoietic cell transplantation in children and adults

Hematopoietic cell transplantation（HCT） is widely performed for neoplastic and non-neoplastic diseases. HCT involves intravenous infusion of hematopoietic progenitor cells from human leukocyte antigen（HLA）-matched donor（allogeneic） or from the patient（autologous）. Before HCT, the patient is prepared with high dose chemotherapy and/or radiotherapy to destroy residual malignant cells and to reduce immunologic resistance. After HCT, chemotherapy is used to prevent graft rejection and graft versus host disease（Gv HD）. Neurological complications are related to the type of HCT, underlying disease, toxicity of the conditioning regimens, immunosuppression caused by conditioning regimens, vascular complications generated by thrombocytopenia and/or coagulopathy, Gv HD and inappropriate immune response. In this review, neurological complications are presented according to time of onset after HCT：（1） early complications（in the first month）-related to harvesting of stem cells, during conditioning（drug toxicity, posterior reversible encephalopathy syndrome）, related to pancytopenia,（2） intermediate phase complications（second to sixth month）-central nervous system infections caused by prolonged neutropenia and progressive multifocal leukoencephalopathy due to JC virus,（3） late phase complications（after sixth month）-neurological complications of Gv HD, second neoplasms and relapses of the original disease.

Graft-versus-leukemia effects from donor lymphocyte infusion after nonmyeloablative allogeneic bone marrow transplantation in mice

BABSTRACTackground Nonmyeloablative allogeneic bone marrow transplantation has been used since the 1990s as a new hematological stem cell transplantation strategy for treating hematological diseases. The purpose of this study was to explore the graft-versus-leukemia (GVL) effects of donor lymphocyte infusions (DLIs) after nonmyeloablative allogeneic bone marrow transplantations, while assessing the declines in treatment-associated morbidity, mortality, and graft-versus-host disease (GVHD).Methods A total of 615 (H-2~k) mice were injected with L615 tumor cells and received 500 cGy (^(60)Coγ-ray) irradiation three days later, followed by an allogeneic bone marrow transplantation (allo-BMT). The allo-grafts consisted of 3×10~7 bone marrow cells and 1×10~7 spleen cells from BALB/C (H-2~d) donor mice. Two days after the allo-BMT, the recipient mice were given 200 mg/kg of cyclophosphamide. Subsequently, recipient mice were infused with either donor spleen cells (2×10~7) on day 14 or 21, or donor spleen cells (5×10~7) pretreated with hydrocortisone and cyclosporin A (CsA) in vitro on day 14 post-BMT.Results The median survival time of mice that received DLI on day 21 and pretreated DLI on day 14 post-BMT was longer than that of controls and the day 14 DLI group (P<0.01). No evidence of severe GVHD was observed in the day 21 DLI group nor in the day 14 treated DLI group. Mixed chimerism was confirmed in the day 14 DLI group, the day 14 treated DLI group, and the day 21 DLI group on the thirteenth day post-transplantation; full donor chimerism was observed two weeks after DLI.Conclusion Donor lymphocyte infusion after nonmyeloablative bone marrow transplantation may reduce transplantation-associated morbidity and mortality while strengthening graft-versus-leukemia effects.

Attenuation of GVHD for Allo-Bone Marrow Transplantation Recipient by FasL-Fas Pathway in an H-2 Haplotype Disparate Mouse Combination

In order to explore a new special and effective way to prevent graft versus host disease (GVHD) after allogenic bone marrow transplantation (allo-BMT), the stem cell antigen-1 (Sca-1) + early hematopoietic cells (EHC) from BALB/c mouse (H-2 d) were introduced with exogenous mouse Fas ligand (mFasL) cDNA gene by the retrovirus-mediated gene transfer and expanded for one week, and then they were co-cultured with the spleen mononuclear cells (SMNC) from BAC mouse (H-2 d×b) as one way mixed lymphocyte reaction (OWMLR). The cytotoxicity of treated BAC mouse SMNC against Na 2 51CrO 4 labeling SMNC from BALB/c mouse was observed. The bone marrow mononuclear cells (BMMNC) from BAC mouse treated by the above methods were transplanted into lethally-irradiated congenic BALB/c mice to observe the occurrence of GVHD. The results showed that the SMNC from BAC mouse after OWMLR with exogenous mFasL cDNA gene-transduced hematopoietic cells (HC) from BALB/c mouse in a ratio of 1 to 5 exhibited an obvious inhibition of the cytotoxicity against the BALB/c mouse spleen cells at different effector/target ratios as compared to the control group (P<0.01). The gradeⅠ GVHD or no GVHD and the 80 % survival rate at day 60 post-BMT were observed in the BALB/c mouse receiving BAC mouse BMMNC treated with similar way, while the grade Ⅱ-Ⅲ GVHD and the 20 % survival rate were noted in the control group (P<0.01). It is suggested that the attenuation of GVHD in allo-BMT recipient could be successfully achieved through FasL-Fas pathway in an H-2 haplotype disparate mouse combination.

Might liver transplantation recipients with primary hepatocellular carcinoma benefit from GVT effect of aGVHD?

We aimed to access if acute graft-versus-host disease （aGVHD） in liver transplantation recipients of hepatocellular carcinoma （HCC） might develop a graft-versus-tumor effect （GVT） other than immunological damage which would benefit prophylaxis of tumor recurrence. Methods： Dynamic observation of 3 cases of liver transplantation recipients of HCC and cirrhosis, which developed manifestations of fever, skin rash, watery diarrhea, pancytopenia and were finally diagnosed as aGVHD. Two of which got recovered from intravenously pulse methylprednisolone, high-dose intravenous immunoglobulin, antibiotics administration simultaneously and promptly withdrawal of oral immunosuppressants. Two survivors were follow-up regularly with biological monitoring and imaging surveillance for tumor recurrence thereafter. Results： Two recipients survived healthily with stable liver graft function and normal serum AFP level and blood routine test. No sign of tumor recurrence was found in repeat imaging examinations for liver graft, lung, brain and other tissue or organs within a period of 96 months and 17 months to date, respectively. Conclusien： Despite of the fatal damage to according organs and tissue, it suggest that aGVHD in liver recipients of HCC may also develop a GVT effect and benefit prophylaxis of tumor recurrence and result in a long-term healthy recipients survival.

Selective Depletion of the Allo-Antigen Specific T Cells by Fas/FasL Pathway by Cytokine IFN-γ and IL-2

To investigate the value of apoptosis of the allo antigen specific T cells induced by Fas/FasL pathway in preventing graft versus host disease (GVHD), the CD34 + cells transfected with FasL or not, used as stimulus cells, were mixed with allo antigen specific T lymphocytes in presence or absence of IFN γand IL 2. After 5 days, apoptosis of T cells was detected by TdT nick end mediated dUTP labeling (TUNEL) and flow cytometry (FCM). The affects of these two cytokines on CD34 + cells in the graft were also compared. The ratio of apoptosis of T cells was 12.1±1.5 % when CD34 + cells transfected with FasL was used as stimulus cells, much higher than that of CD34 + cells non transfected (3.2 ±1.1 %, P <0.01). And in presence of IFN γ or IL 2, the ratio reached 20.1±2.3 %, 17.6±1.3 % respectively ( P <0.01). However, IFN γ up regulated Fas expression of CD34 + cells and increased the sensibility of CD34 + cells to soluble FasL(sFasL); IL 2 showed no such affect. It is possible to induce apoptosis of the allo antigen specific T cells of grafts activated by allo antigen by exogenous Fas ligand expressed on recipient cells and this might provide a new approach for preventing GVHD and IL 2 may be more suitable for clinical application.

A novel approach to human leukocyte antigen-mismatched transplantation in patients with malignant hematological disease

Background Many patients requiring allogeneic hematopoietic stem cell transplantation (HSCT) do not have an human loukocyte antigen (HLA) matched donor Alternative donors, such as HLA mismatched family donors, are associated with higher rates of graft rejection and acute graft versus host disease (aGVHD) if T cells are not first depleted We developed a new technique for HLA mismatched allogeneic HSCT using G CSF primed bone marrow plus G CSF mobilized peripheral blood stem cells without ex vivo T cell depletion Methods In this study, 58 patients, including 33 with high risk or advanced leukemia, were transplanted with cells from an HLA haploidentical family donor with 1-3 mismatched loci After conditioning, patients received G CSF primed bone marrow grafts that had not been depleted ex vivo of T cells, in combination with G CSF mobilized peripheral blood stem cells, as well as GVHD prophylaxis Result All patients achieved sustained, full donor type engraftment The incidence of grade Ⅱ Ⅳ aGVHD was 37 9%, including 3 patients with grade Ⅲ Ⅳ aGVHD The development of aGVHD was not associated with the extent of HLA disparity Chronic GVHD was observed in 30 of 51 evaluable patients (65 4%) Fourteen patients died among whom 7 died of recurrent disease and 7 of transplant related complications Forty four of the 58 patients survived, and 42 remained disease free at the time of a median follow up of 12 months (3 5 to 39 5 months) The 2 year probabilities of disease free survival were 74 8% and 69 3% for standard and high risk patients, respectively Conclusion We developed a new method to use bone marrow from haploidentical family donors without ex vivo T cell depletion, in combination with G PBSCs, as a source of stem cells even in cases of HLA mismatched transplantation

Treatments of disease relapse after allogeneic stem cell transplantation focusing on donor lymphocyte infusion

Hematopoietic stem cell transplantation （SCT） is a potentially curative treatment for patients with hematologic malignancies, such as acute myeloid leukemia （AML） and myelodysplastic syndromes （MDS）. There has been tremendous progress in the past several decades in allogeneic SCT with better outcomes through improvements in supportive care, expansion of stem cell donor options （HLA-matched unrelated donors （MUD）, haploidentical related donors, and cord blood units （CBUs） etc.）, and introduction of better tolerated reduced intensity conditioning （RIC） regimens.

Stable clonal expansion of the T-cell receptor Vβ6, Vβ17 and Vβ19 T cells in a cGVHD case using genescan analysis

Objective To investigate the distribution and clonality of the T-cell receptor (TCR) Vβ repertoire in chronic graft versus host disease (cGVHD).Methods The complementarity determining region 3 (CDR3) of the TCRβ gene with 24 variable regions was amplified in peripheral blood mononuclear cells drawn from one cGVHD patient after allogenic bone marrow transplantation (allo-BMT) 35, 39, 43 or 45 months respectively, using RT-PCR, to observe the expression of TCR Vβ repertoire T cells. The PCR products were further analyzed by genescan to evaluate clonality of T cells. Ressults Fourteen or 16 TCR Vβ subfamily T ceils were detected in each sample of cGVHD case. Oligoclonal T cells were identified in TCR Vβ 6, 16, 17, 19 and 21 subfamilies. The stable clonal T cells in all samples were identified in Vβ6, Vβ17 and Vβ21 subfamilies.Conclusion Skewing distribution and stable clonal expansion of T cells can be found in cGVHD cases and it may be related to the initiation of cGVHD.

Haploidentical hematopoietic stem cell transplantation for pediatric patients with chronic active Epstein-Barr virus infection:a retrospective analysis of a single center

Background This study aimed to evaluate the feasibility and clinical effect of haploidentical hematopoietic stem cell transplantation(haplo-HSCT)for the treatment of pediatric patients with chronic active Epstein-Barr virus infection(CAEBV).Methods Children with CAEBV who did not have matched donors and underwent haplo-HSCT in Beijing Children's Hospital,Capital Medical University,from October 2016 to June 2020 were analyzed retrospectively.Data relating to the clinical manifestations,engraftment,and prognosis of the children were extracted from medical records.Results Twenty-five patients,including 16 males and 9 females,with an onset age of 5.0±2.6 years and a transplantation age of 6.9±2.9 years,were enrolled irnhis study.The mean time from diagnosis to transplantation was 3.8(2.0-40.2)months.The mean observation time was 19.0±12.0 months.Three patients received the reduced intensity conditioning regimen,and the remaining patients all received the modified myeloablative conditioning regimen.By the end of the follow-up,23 patients were characterized by disease-free survival(DFS),22 were characterized by event-free survival(EFS).and two died.One of the patients died of thrombotic microangiopathy(TMA),and another died of graft versus host disease(GVHD);this patient discontinued the treatment for economic reasons.The 3-year overall survival(OS)rate was estimated to be 92.0%±5.4%,and the 3-year EFS rate was estimated to be 87.4%±6.8%.All active patients survived after HSCT event-free.Acute GVHD degrees 1-3 were observed in ten patients(40.0%),and degree IV was observed in six(24.0%),who were all cured except for one patient.Chronic GVHD was observed in nine(36.0%),and most of these cases were mild.The incidence of TMA and veno-occlusive disease(VOD)was 28.0%and 4.0%.Conclusions Haploidentical hematopoietic stem cell transplantation is safe and effective in the treatment of pediatric CAEBV and can be used as an alternative therapy without matched donors or emergency transplantation.Patients with active disease before HSCT also benefited from haplo-HSCT.Haplo-HSCT requires careful monitoring for complications,such as GVHD and TMA.Early detection of TMA and timely treatment can reduce mortality and can improve the survival rate.