Brian Kornblit

Association of HMGB1 polymorphisms with outcome in patients with systemic inflammatory response syndrome

IntroductionHigh mobility group box 1 protein (HMGB1) is a pleiotropic cytokine, recently implicated in the pathophysiology of the systemic inflammatory response syndrome (SIRS) and sepsis. Data from experimental sepsis models show that administration of anti-HMGB1 antibodies significantly decreased mortality, even when administration was delayed for 24 hours, providing a window of opportunity for therapeutic intervention if transferred into a clinical setting. Whether genetic variation in the human HMGB1 gene is associated with disease susceptibility is unknown.MethodsWe sequenced the HMGB1 gene in 239 prospectively monitored patients with SIRS admitted to an intensive care unit and we measured the corresponding HMGB1 serum concentrations. Blood donors served as control individuals. Outcome parameters according to different HMGB1 genotypes were compared.ResultsHomozygosity and heterozygosity for a promoter variant (-1377delA) was associated with a decreased overall 4-year survival (15% versus 44%, hazard ratio = 1.80; P = 0.01) and with a decreased number of SIRS criteria. Carriage of an exon 4 variant (982C>T) was significantly associated with an increased number of SIRS criteria, a higher Simplified Acute Physiology Score II score, a lower PaO2/FiO2 ratio and lower serum HMGB1 levels (P = 0.01), and with a significantly higher probability of early death due to infection (P = 0.04). HMGB1 was undetectable in the control individuals.ConclusionThe present article is the first report of clinical implications of variation in the human HMGB1 gene. Two polymorphisms were determined as significant risk factors associated with early and late mortality, which may provide insight into the molecular background of SIRS and sepsis, suggesting a possible role for HMGB1 genetics in future prognostic evaluation.

Association of HMGB1 polymorphisms with outcome after allogeneic hematopoietic cell transplantation.

Several studies have demonstrated that genetic variation in cytokine genes can modulate the immune reactions after allogeneic hematopoietic cell transplantation (HCT). High mobility group box 1 protein (HMBG1) is a pleiotropic cytokine that functions as a pro-inflammatory signal, important for the activation of antigen presenting cells (APCs) and propagation of inflammation. HMGB1 is implicated in the pathophysiology of a variety of inflammatory diseases, and we have recently found the variation in the HMGB1 gene to be associated with mortality in patients with systemic inflammatory response syndrome. To assess the impact of the genetic variation in HMGB1 on outcome after allogeneic HCT, we genotyped 276 and 146 patient/donor pairs treated with allogeneic HCT for hematologic malignancies following myeloablative (MA) or nonmyeloablative (NMA) conditioning. Associations between genotypes and outcome were only observed in the cohort treated with MA conditioning. Patient homozygosity or heterozygosity for the-1377delA minor allele was associated with increased risk of relapse (hazard ratio [HR] 2.11, P = .02) and increased relapse related mortality (RRM) (P = .03). Furthermore, patient homozygosity for the 3814C > G minor allele was associated with increased overall survival (OS; HR 0.13, P = .04), progression free survival (PFS; HR 0.30, P = .05) and decreased probability of RRM (P = .03). Patient carriage of the 2351insT minor allele reduced the risk of grade II to IV acute graft-versus-host disease (aGVHD) (HR 0.60, P = .01), whereas donor homozygosity was associated with chronic GVHD (cGVHD) (HR 1.54, P = .01). Our findings suggest that the inherited variation in HMGB1 is associated with outcome after allogeneic HCT following MA conditioning. None of the polymorphisms were associated with treatment-related mortality (TRM).

Durable donor engraftment after radioimmunotherapy using α-emitter astatine-211-labeled anti-CD45 antibody for conditioning in allogeneic hematopoietic cell transplantation

To reduce toxicity associated with external γ-beam radiation, we investigated radioimmunotherapy with an anti-CD45 mAb labeled with the α-emitter, astatine-211 ((211)At), as a conditioning regimen in dog leukocyte antigen-identical hematopoietic cell transplantation (HCT). Dose-finding studies in 6 dogs treated with 100 to 618 μCi/kg (211)At-labeled anti-CD45 mAb (0.5 mg/kg) without HCT rescue demonstrated dose-dependent myelosuppression with subsequent autologous recovery, and transient liver toxicity in dogs treated with (211)At doses less than or equal to 405 μCi/kg. Higher doses of (211)At induced clinical liver failure. Subsequently, 8 dogs were conditioned with 155 to 625 μCi/kg (211)At-labeled anti-CD45 mAb (0.5 mg/kg) before HCT with dog leukocyte antigen-identical bone marrow followed by a short course of cyclosporine and mycophenolate mofetil immunosuppression. Neutropenia (1-146 cells/μL), lymphopenia (0-270 cells/μL), and thrombocytopenia (1500-6560 platelets/μL) with prompt recovery was observed. Seven dogs had long-term donor mononuclear cell chimerism (19%-58%), whereas 1 dog treated with the lowest (211)At dose (155 μCi/kg) had low donor mononuclear cell chimerism (5%). At the end of follow-up (18-53 weeks), only transient liver toxicity and no renal toxicity had been observed. In conclusion, conditioning with (211)At-labeled anti-CD45 mAb is safe and efficacious and provides a platform for future clinical trials of nonmyeloablative transplantation with radioimmunotherapy-based conditioning.

Haematopoietic cell transplantation with non-myeloablative conditioning in Denmark: disease-specific outcome, complications and hospitalization requirements of the first 100 transplants

We analysed the outcome and hospitalization requirements of the first 100 patients (Hodgkins disease (HD), N=13; multiple myeloma (MM), N=14; CLL, N=12; non-Hodgkins lymphoma (NHL), N=17; myelodysplastic syndrome (MDS), N=18; AML, N=24 and CML, N=2) treated in Denmark with haematopoietic cell transplantation after non-myeloablative conditioning with TBI 2 Gy±fludarabine. The cumulative incidence of acute GVHD grade II–IV and extensive chronic GVHD was 67 and 49%. After a median follow-up of 534 days, the overall survival, PFS, relapse-related mortality and treatment-related mortality were 59, 50, 25 and 17%, respectively. Patients with CLL, NHL, AML and MDS with <5% blasts at any time had a favourable outcome with a PFS of 61–71%. Patients with MM, HD and MDS and a history of ⩾5% blasts had a less favourable outcome with a PFS of 19–38% (P=0.001). The cumulative incidence of discontinuation of immunosuppression was 37%. During the first and second year post transplant, patients experienced a mean of 41 and 13 outpatient clinic visits, and 53 and 16 days of hospitalization. Sixteen patients were admitted to the intensive care unit, of whom eight are still alive. In conclusion, transplantation outcomes were encouraging, but complications requiring admission and outpatient clinic visits occur frequently post transplant.

The Prognostic Value of YKL-40 Concentrations in Nonmyeloablative Conditioning Allogeneic Hematopoietic Cell Transplantation

Increased plasma concentrations of YKL-40, also called chitinase-3-like-1 protein (CHI3L1), have been correlated with disease severity in a variety of malignant and inflammatory diseases. The objective of the current study was to assess pretransplant recipient and donor CHI3L1 polymorphisms and plasma YKL-40 concentrations as prognostic biomarkers in a cohort of 149 patients treated with hematopoietic cell transplantation (HCT) after nonmyeloablative conditioning for hematologic malignancies. Recipients with pretransplant YKL-40 concentrations above the age-adjusted 95th percentile (high) had higher relapse-related mortality (33% versus 18%, P = .04; hazard ratio (HR) = 4.41, P = .01), lower progression-free survival (38% versus 64%, P < .01; HR = 2.84, P = .01), and overall survival (42% versus 69%, P = .01; HR = 3.09, P = .01). Recipients transplanted with donors with high YKL-40 concentrations had an increased probability and risk of grade 2-4 acute graft-versus-host disease (aGVHD) (93% versus 62%, P < .01; HR = 2.25, P = .02). CHI3L1 polymorphisms were associated with plasma YKL-40 concentrations, but not with clinical outcomes. In conclusion, our study suggests that plasma YKL-40 could function as a biomarker for relapse risk and treatment-related toxicity, and possibly as a tool complementing clinical risk scores such as the HCT comorbidity index.

Longitudinal follow-up of response status and concomitant immunosuppression in patients treated with extracorporeal photopheresis for chronic graft versus host disease

Improvement in chronic graft vs. host disease (cGvHD) following treatment with extracorporeal photopheresis (ECP) has been shown previously. However, the effect is often measured at only one point in time or as best response. Chronic GvHD activity fluctuates over time, so we retrospectively evaluated cGvHD responses in 54 patients with primarily moderate or severe cGvHD throughout the ECP treatment course and after stopping ECP. The dominant response was partial remission (PR) in 33 patients, no change (NC) in 10 patients, progressive disease (PD) in 10 patients and complete remission (CR) in one patient. Response rates and reduction in glucocorticoid dose reached a plateau after nine months. The main reason for stopping ECP was the absence of further improvement. Flares in cGvHD activity were seen in 36 patients. Additional treatment during ECP was administered to 29 patients. Failure free survival with response was achieved for 52% of patients at 6 months and 43% at 1 year. Our study confirms that ECP is a safe option for cGvHD therapy. The majority of the patients experience improvement and reduction in glucocorticoid dose but flares in cGvHD activity and the need for additional immunosuppression are seen frequently.

Extracorporeal photopheresis is a valuable treatment option in steroid-refractory or steroid-dependent acute graft versus host disease—experience with three different approaches

Extracorporeal photopheresis (ECP) is increasingly used in the treatment of acute graft versus host disease (aGvHD). It is recognized as an immunomodulatory therapy that decreases inflammation and possibly induces immune tolerance [1]. In our center, we have used ECP for aGvHD since the year 2014. Initially ECP was used as salvage therapy if the conventional second-line therapy with infliximab was insufficient. Due to good results and increased availability, we increasingly used ECP as secondline therapy either in combination with infliximab or alone. We hypothesized that addition of ECP would improve response rates and survival for the patients. In this study, we present our treatment outcomes for three approaches to the use of ECP for aGvHD. We assess response at predetermined time points to facilitate comparison with existing and future studies on second-or-further-line therapies for aGvHD as recently proposed [2, 3]. A single investigator (MN) retrospectively collected data from patient records from 38 patients treated with ECP between January 2014 and August 2017 at the Department of Hematology at Rigshospitalet, Denmark. All patients gave informed consent for the use of data and the study was conducted in accordance with guidelines from the regional Ethics Committee and the Danish Data Protection Agency. Patient and treatment characteristics are shown in Table 1. First-line treatment of aGvHD was 2 mg/kg prednisolone or methylprednisolone. Patients were referred to ECP at the discretion of the treating physician if they were steroidrefractory (progression after 3 days or no improvement of aGvHD after 7 days), or steroid-dependent (inability to taper steroids without recurrence of aGvHD symptoms) and/or had insufficient response to second-line therapy with infliximab. Based on the different approaches to the use of ECP over time, we describe patients in three categories: (1) ECP-salvage where ECP was provided after more than 7 days of infliximab treatment (n= 12), (2) ECP-early where ECP was initiated less than 7 days after first dose of infliximab (n= 15), and (3) ECP-only where no infliximab was administered (n= 11). In both the ECP-salvage and the ECP-early groups, infliximab was continued until response was achieved. Infliximab was administered with 10 mg/kg once or twice a week at the discretion of the treating physician. ECP was performed with the “in-line” technique using the Therakos Cellex equipment following the manufacturer’s instructions. Response was assessed with repeated grading of aGvHD on day 7 and 28 after starting ECP using the modified Glucksberg criteria [4]. We also assessed the best response achieved at any time point in the individual patient. The severity of aGvHD was defined as the overall grade of aGvHD on the day ECP was initiated. Complete remission (CR) was defined as complete resolution of all aGvHD manifestations and very good partial remission (VGPR) as an approximation of a CR as previously described [2]. Partial remission was defined as a reduction in stage in at least one organ without deterioration in another, no change as stable stage and involvement of organs and progressive disease (PD) as progression in one organ regardless of improvement in other organs. Additional therapy was considered PD. * Marietta Nygaard marietta.nygaard@regionh.dk

YKL-40 in allogeneic hematopoietic cell transplantation after AML and myelodysplastic syndrome

YKL-40, also called chitinase-3-like-1 protein, is an inflammatory biomarker that has been associated with disease severity in inflammatory and malignant diseases, including AML, multiple myeloma and lymphomas. The objective of the current study was to assess the prognostic value of pretransplant recipient and donor plasma YKL-40 concentrations in patients with AML (n=624) or myelodysplastic syndrome (n=157) treated with allogeneic hematopoietic cell transplantation (HCT). In recipients, the plasma YKL-40 concentrations were increased when the HCT-comorbidity index was ⩾5 (P=0.028). There were no significant associations between plasma YKL-40 concentrations in recipients and any outcome measures. In donors with YKL-40 plasma concentrations above the age-adjusted 95th percentile, a trend toward increased grade II–IV acute GvHD in recipients was observed (adjusted hazard ratio 1.39 (95% confidence interval 1.00–1.94), P=0.050), with no significant associations with overall survival, treatment-related mortality or relapse. In conclusion, our study shows that YKL-40 does not aid risk stratification of patients undergoing allogeneic HCT, but suggests that YKL-40 may aid donor selection when multiple, otherwise equal, donors are available.