| Objective:Nowadays, allogeneic hematopoietic stem cell transplantation (allo-HSCT), as a curable methold for malignant diseases of hematological system, has been more and more widely used. aGVHD and infections are due to the most important causes of mortality. Ⅱ-Ⅳ aGVHD rate was40%(10%-80%) after allo-HSCT, in which about30%-60%of patients suffered from steroid-refractory severe (Ⅲ-Ⅳ) aGVHD. The standard recommended treatment scheme for steroid-refractory severe aGVHD is not determined, only10%-30%of patients could achieve complete remission and long-term survival. T cells play the key roles in the development of aGVHD after allo-HSCT, and the different subsets play different roles. Investigation on the reconstruction of T cell immune function and its’cytokines in the occurrence of aGVHD has become one of the hottest topic in aGVHD research.We retrospectively analyzed the incidence of aGVHD, and the metholds of prevention and treatment for aGVHD after different types of transplantation (MSD,URD,HRD-HSCT) in our center in recent5years, observed the clinical effect of transplantation, to explore the clinical strategy on prevention and treatment of aGVHD. We used CD25monoclonal antibody and tumor necrosis factor receptor-antibody fusion protein for steroid-refractory severe aGVHD, observe the safety and efficacy of the treatment. Furtherly, we monitored the key T lymphocyte subsets and its’cytokines, to explore the relationship between the characteristics of T cell subsets and the process of aGVHD. We desire to find some biomarkers and establish early diagnosis index for aGVHD, furthermore find an important target for immunotherapy. Ultimately the strategy could reduce aGVHD related mortality and improve long-term disease-free survival in transplantation patients.Part1:Prevention and Treatment of acute Graft-versus-Host Disease after Allogeneic Hematopoietic Stem TransplantationMethods:We retrospectively analyzed305patients after three types of allo-HSCT (MSD, URD, HRD) in our center during the period of March2008through March2013.,observed the occurrence characteristics of aGVHD and the clinical effect of transplantation, explore the clinical strategy on prevention and treatment of aGVHD. the incidence rate of aGVHD, overall survival rate (OS) and disease free survival rate (DFS) were evaluated with Kaplan-Meier curves. Univariate and multivariable analysis were used to evaluate the risk factors for development of aGVHD.Results:305patients were included in the study.177males,128females.90MSD-HSCT patients,116URD-HSCT patients,99HRD-HSCT patients. All patients achieved neutrophil engraftment in MSD, URD, HRD-HSCT respectively for12days (7-17days),12days (8-19days),12days (8-24days), median time to platelet engraftment was12days (7-58days),13days (6-24days),15days (6-53days) respectively. Cumulative incidences of grades Ⅱ-Ⅳ aGVHD were15.6%,39.7%, and 42.4%for patients undergoing transplantation using MSDs, URDs, and HRDs, respectively. Cumulative incidences for severe aGVHD were5.6%,12.9%nd7.2%, respectively. Five-year OS rates after transplantation were79.8%,63.5%and60.8%for MSD, URD and HRD transplantation, respectiely. Five-year DFS rates after transplantation were63.6%,58.4%and58.3%between the three donor types. Multivariate Cox regression analysis for aGVHD in the total cohort of305patients confirmed that alternative donors had adverse impact on the risk of grades II-IVaGVHD (for URD and HRD). Matching a female donor with a male patient was found to be another significant factor.Conclusion:Grades Ⅱ-Ⅳ and severe aGVHD were significantly more frequent in patients undergoing URD or HRD-HSCT compared with those undergoing MSD-HSCT. However, the incidences of aGVHD were comparable in patients receiving transplants from HRDs to those from URDs. Five-year OS rates after MSD-HSCT were comparable to URD-HSCT, whereas superior to HRD-HSCT. Five-year DFS rates after transplantation were similar among the three donor types. Multivariate Cox regression analysis for aGVHD confirmed that alternative donors (for URD and HRD) and Matching a female donor with a male patient have adverse impact on the risk of grades II-IV aGVHD.Part2:Study on the the Treatment of Steroid-Refractory Severe acute Graft-versus-Host DiseaseMethods:56patients with steroid-refractory severe aGVHD were studied retrospectively from September2001to October2013.27cases during the period from September2001to September2009were treated with traditional second-line aGVHD therapy, such as high dose of methylprednisolone,CD3monoclonal antibody, budesonide, FK506, MTX, CD25monoclonal antibody, plasmapheresis (control group).29cases since October2009were treated with CD25monoclonal antibody and tumor receptor necrosis factor TNF-α receptor-antibody fusion protein (combined treatment group). We evaluate the safety and efficacy of the tow types of therapy. Transplantation related mortality, relapse rate, overall survival and disease free survival were evaluated with Kaplan-Meier curves.Results:56cases of steroid refractory aGVHD patients achieved hematopoietic reconstitution, and engraftment evidence (STR) showed complete donor chimerism3-4weeks after allo-HSCT.26cases(89.7%) in combined treatment group had experienced response, of which23cases (79.3%) achieved complete remission (CR).16cases (55.2%) is alive till now, median survival time was21.5months (6-51months). One-year and four-year OS rate were60.8%and51.0%, respectively. One-year and four-years DFS rate are the same as OS.12cases (44.4%) in the control group had experienced response, of which8cases (29.6%) achieved CR.4cases (14.8%) is alive till now, median survival time was67.5months (62-68months). One-year and four-year OS rate were25.9%and14.8%, respectively. One-year and four-year DFS rate were22.2%and11.1%, respectively.Conclusion:CD25monoclonal antibody combined with TNF-a receptor-antibody fusion protein as the second-line therapy for steroid-refractory severe aGVHD was safe and effective. It effectively increased the CR rate, reduced transplant related mortality, and do not increase the relapse rate of malignant disease. If used in early period of the steroid-refractory severe aGVHD, It could improve the long-term overal survival rate and disease free survival rate. Part3:Investigation of the key T Cells and Cytokines of aGVHD after Allogeneic Hematopoietic Stem Cell TransplantationMethods:64patients were included in the study, from May2013to January2014. Blood samples of these patients were monitoring every week. Treg, Thl and Th7cells number were detected by flow cytometry. Serum levels of IL-2, IL-6, IL-10, IL-17, TNF-a and IFN-y were detected by flow cytometry (CBA). Elisa technique was used for the detection of serum TGF-p level.Results:36patients (56.3%) suffered from II-IV aGVHD, and10cases (15.6%) among them was diagnosed of Ⅲ-ⅣaGVHD. Before the onset of aGVHD, Treg,Thl,Th17cells levels had no statistical difference between aGVHD patients and non aGVHD patients. In aGVHD patient, serum levels of IL-2and TGF-β elevated in the early stage of aGVHD. IL-2, IL-10, TGF-β serum levels after aGVHD was significantly higher than that in non aGVHD patients, and Treg cells number was significantly lower than that of patients without aGVHD. Using ROC and logistic regression analysis, we found a composite biomark panel(IL-2, IL-10and Treg cell),which could optimally discriminated patients with and without aGVHD, the formula is:1.656+0.103xIL-2-0.052xIL-10-0.037xTreg. ROC curve of composite panel is0.89(95%CI,0.78-0.99, P=0.0002), which is larger than that of any single index.Conclusion:Increased IL-2,IL-10,TGF-P serum levels in early stage after allo-HSCT can help to establish the clinical diagnosis of aGVHD, and which is expected to provide a clinical basis for further target immunotherapy. Treg cell level was negatively related to the onset of aGVHD. Furthermore, we found a composite biomark panel(IL-2, IL-10and Treg cell),which could optimally discriminated patients with and without aGVHD. It could provide a reliable basis for early diagnosis of aGVHD. |
PDF Full Text Request