Yoshinobu Takemoto

Complications after bone marrow transplantation are manifestations of systemic inflammatory response syndrome

Bone marrow transplantation has been established as a useful treatment for various hematological disorders and is now performed widely, but the mortality rate is still high due to various complications. A clear therapeutic policy for such complications has not yet been established because of their complex nature. We investigated whether the major complications occurring after bone marrow transplantation could be classified as aspects of the systemic inflammatory response syndrome. Subjects were 10 patients who developed severe complications after bone marrow transplantation (graft-versus-host disease, thrombotic microangiopathy, respiratory disorders, and cytomegalovirus interstitial pneumonitis) and 16 patients without complications. Their symptoms, serum cytokines, and factors related to vascular endothelial damage were compared before and after transplantation. Whereas all 10 patients who developed complications had fever in the aplastic phase after transplantation, 15 of the 16 patients without complications remained afebrile (P < 0.001, t-test). When compared with the patients who did not develop complications, the patients with complications also showed significantly higher cytokine levels during the recovery phase after transplantation (P < 0.0001, t-test). Thus, the patients with complications developed fever in the aplastic phase and showed an increase of cytokines during the recovery phase, which triggered the occurrence of vascular endothelial damage shown by factors such as the thrombomodulin and plasminogen activator inhibitor type 1. This sequence of events corresponds with that occurring during systemic inflammatory response syndrome, so many of the complications of bone marrow transplantation can be considered as manifestations of this syndrome. Bone Marrow Transplantation (2000) 26, 419–426.

Elevated interleukin (IL)-18 levels during acute graft-versus-host disease after allogeneic bone marrow transplantation.

Acute graft‐versus‐host disease (aGVHD) after allogeneic bone marrow transplantation (BMT) is mediated by grafted T lymphocytes after their polarization into type 1 T cells. Interleukin (IL)‐18, a novel immunoregulatory cytokine, strongly stimulates type 1 T cells, therefore we postulated that IL‐18 may be involved in the pathogenesis of aGVHD. Using an enzyme‐linked immunosorbent assay (ELISA), we serially measured serum levels of IL‐18 in 37 patients with haematological malignancy before and after allogeneic BMT. Patients with aGVHD had high levels of IL‐18 that strongly correlated with the severity of aGVHD. We also found that they showed reduced serum levels of IL‐18 after appropriate treatment or at a state of resolution. IL‐18 levels were not affected by the pretransplant regimen, engraftment or bacterial infection. Compared with circulating interferon (IFN)‐γ or IL‐12 levels, serum levels of IL‐18 showed a more sensitive and specific correlation with the disease status of aGVHD. These findings suggest that IL‐18 may play important roles in the pathogenesis of aGVHD and that measurement of serum IL‐18 levels can be useful indicator of aGVHD.

Oral eicosapentaenoic acid for complications of bone marrow transplantation.

The ‘systemic inflammatory response syndrome’ (SIRS) may represent the underlying cause of complications after bone marrow transplantation (BMT). This study was conducted to determine whether blocking the etiologic factors of SIRS could improve the complications of BMT. Sixteen consecutive patients with unrelated donors were allocated alternately to two groups. Seven patients received 1.8 g/day of eicosapentaenoic acid (EPA) orally from 3 weeks before to about 180 days after transplantation, while nine patients did not. These two groups were compared with respect to complications, survival, and various cytokines and factors causing vascular endothelial damage. All seven patients receiving EPA survived and only two had grade III graft-versus-host disease (GVHD). Among the nine patients not receiving EPA, three had grade III or IV GVHD. In addition, thrombotic microangiopathy developed in four patients and cytomegalovirus disease occurred in four. Five patients died in this group. The levels of leukotriene B4, thromboxane A2, and prostaglandin I2 were significantly lower in patients receiving EPA than in those not receiving it (all P < 0.01). Cytokines such as tumor necrosis factor-α, interferon-γ, and interleukin-10 were also significantly decreased by EPA (P < 0.05), as were factors causing vascular endothelial damage such as thrombomodulin and plasminogen activator inhibitor-1 (P < 0.05). The survival rate was significantly higher in the group given EPA (P < 0.01). EPA significantly reduced the complications of BMT, indicating that these complications may be manifestations of the systemic inflammatory response syndrome. Bone Marrow Transplantation (2001) 28, 769–774.

Endothelial damage caused by cytomegalovirus and human herpesvirus-6

Summary:Infection with cytomegalovirus (CMV) or human herpesvirus-6 (HHV-6) may have a role in vascular endothelial damage after bone marrow transplantation (BMT). In total, 41 patients who underwent BMT were classified into four groups (12, 10, 7, and 12 patients who were infected with both CMV and HHV-6, CMV alone, HHV-6, and neither virus, respectively). Levels of thrombomodulin, plasminogen activator inhibitor-1, and cyclic GMP were 7.5±1.7 FU/ml, 76.4±24.1 ng/ml, and 9.51±1.1 pmol/ml, respectively, in the patients with both viruses, while the respective values were 2.9±0.67 FU/ml, 33.8±8.09 ng/ml, and 2.90±1.4 pmol/ml in patients infected with CMV alone, 4.8±0.96 FU/ml, 47.7±9.21 ng/ml, and 5.48±0.55 pmol/ml in patients with HHV-6 alone, and 1.6±0.39, 17.5±7.88 ng/ml, and 0.45±0.3 in those with neither virus. All three markers were significantly higher in the three groups with at least one virus than in the uninfected patients (P<0.05), and were also higher in patients with HHV-6 alone than in those with CMV alone (P<0.05). These results suggest that infection by CMV or HHV-6 causes vascular endothelial injury, with HHV-6 having a stronger effect than CMV, and combined infection having a stronger effect than either virus alone. Such viral infection may be a cause of thrombotic microangiopathy after BMT.

Predicting the severity of graft-versus-host disease from interleukin-10 levels after bone marrow transplantation.

Acute graft-versus-host disease (GVHD) is the most important complication of allogeneic bone marrow transplantation. We investigated the possibility of predicting severe acute GVHD using plasma interleukin-10 levels in 31 patients who underwent allogeneic bone marrow transplantation. In patients with acute GVHD, the interleukin-10 (IL-10) level increased significantly from the aplastic phase through the leukocyte recovery phase after transplantation (P < 0.05, paired t-test). The ratio of the IL-10 level in the aplastic phase to that in the leukocyte recovery phase was significantly correlated with the severity of acute GVHD (P < 0.05, t-test), and the incidence of grade III or IV disease was significantly increased (P < 0.0001). since il-10 antagonizes various other cytokines that induce acute gvhd, determination of the il-10 level is equivalent to assessing the total production of cytokines promoting gvhd. the ratio of the il-10 level in the aplastic phase to that in the recovery phase seems to be useful for predicting the subsequent risk of acute gvhd.

Expression of the antiapoptosis gene survivin in human leukemia

Loss of the inhibition of apoptosis is important in leukemogenesis and may influence the prognosis. Survivin is an inhibitor of apoptosis that shows selective expression during fetal development and in human malignancies. Survivin expression was examined in human leukemias using the reverse transcriptase—polymerase chain reaction. Survivin gene expression was detected in 17 of 31 patients with acute myelocytic leukemia and 11 of 16 patients with acute lymphocytic leukemia but was not identified in normal bone marrow cells. Survivin expression was lower in patients with M3 acute myelocytic leukemia than in patients with other types of acute leukemia. Survivin was not detected in the chronic phase of chronic myelocytic leukemia but was observed in 5 of 7 patients with chronic myelocytic leukemia in blastic crisis. These findings suggest a relationship between survivin gene expression and hematopoietic cell differentiation. In fact, survivin gene expression was down-regulated during the differentiation of HL-60 cells after treatment with dimethyl sulfoxide or all—trans-retinoic acid. Moreover, the disease-free survival rates of patients with survivin expression were lower than in patients without survivin expression. Accordingly, survivin may have a role in leukemogenesis as well as in other malignancies. Detecting survivin may also provide prognostic information.

Impact of human leucocyte antigen mismatch on graft-versus-host disease and graft failure after reduced intensity conditioning allogeneic haematopoietic stem cell transplantation from related donors.

The impact of human leucocyte antigen (HLA) incompatibility between donor and recipient on graft‐versus‐host disease (GVHD) and graft failure after reduced‐intensity conditioning stem cell transplantation (RICT) remains to be elucidated. We retrospectively analysed outcome in 341 patients who underwent RICT from related donors for haematological malignancies. The overall cumulative incidence of grade II–IV acute GVHD (aGVHD) was 40% for all subjects; 39% in recipients with HLA‐matched donors, 44% in those with one‐locus‐mismatched donors, and 50% in those with two‐ to three‐loci‐mismatched donors. In a Cox regression model adjusted for potential confounders, the tendency for grade II–IV aGVHD (P = 0·01), chronic GVHD (cGVHD) (P = 0·05) and graft failure (P = 0·033) increased with HLA disparity. Use of peripheral blood grafts instead of marrow was a risk factor for cGVHD. Use of antithymocyte globulin was associated with reduced aGVHD and cGVHD. Overall survival (OS) in recipients of two‐ to three‐loci‐mismatched RICT at 2 years (18%) was significantly worse than that in patients who received one‐locus‐mismatched RICT (51%) and HLA‐matched RICT (48%) (P < 0·0001). A two‐ to three‐loci mismatch was identified as an independent risk factor for OS (P < 0·001), but there was no significant difference in OS between HLA‐matched and one‐locus‐mismatched RICT. HLA incompatibility between the donor and recipient is an important risk factor for graft failure, aGVHD, cGVHD and OS after RICT. RICT from a one‐locus‐mismatched donor may represent an effective alternative approach in patients with high‐risk malignancies who lack HLA‐matched related donors.

Evaluation of CMV/human herpes virus-6 positivity in bronchoalveolar lavage fluids as early detection of acute GVHD following BMT: evidence of a significant relationship

We evaluated the relationship between CMV and human herpes virus-6 (HHV-6) reactivation and the incidence of grades 2 to 4 acute GVHD post BMT. Bronchoalveolar lavage fluid (BALF) samples extracted from 54 BMT recipients on post-BMT day 35 were analyzed by PCR for detection of CMV DNA, HHV-6 DNA and CMV plus HHV-6 DNA. CMV DNA was detected in 26 patients and 13 (50%) developed grades 2 to 4 acute GVHD. Of the 28 who were CMV negative, only six (21.4%) developed grades 2 to 4 acute GVHD. HHV-6 was detected in 18 patients, and 11 (61.1%) developed grades 2 to 4 acute GVHD. Of the 36 who were HHV-6 negative, only eight (22.2%) developed grades 2 to 4 acute GVHD. CMV and HHV-6 were detected in 13 patients, and eight (61.5%) developed grades 2 to 4 acute GVHD. Of the 23 who were negative for both CMV and HHV-6, only three (13%) developed grades 2 to 4 acute GVHD. In all experiments, the difference between the groups was significant (P < 0.05, P < 0.05 and P < 0.01, respectively). we conclude that herpes virus infection, in particular cmv concurrent with hhv-6 reactivation, is predictive of moderate to severe acute gvhd. Bone Marrow Transplantation (2000) 26, 77–81.

Thrombotic microangiopathy following allogeneic bone marrow transplantation

Thrombotic microangiopathy is one of the complications of bone marrow transplantation and is related to other complications such as graft-versus-host disease, veno-occlusive disease, diffuse alveolar hemorrhage, and cytomegalovirus infection. Thrombotic microangiopathy occurred in three out of 12 patients who underwent allogeneic bone marrow transplantation over the past 1 year at our department. We compared the changes in cytokines and other molecules between patients with and without microangiopathy from before conditioning to the early post-transplantation period. All three patients with microangiopathy showed a significant increase of interleukin-12 at the time of leukocyte recovery after transplantation (two-way layout analysis of variance; P < 0.05), while none of the patients without microangiopathy showed an increase of interleukin-12. no significant differences were found between the two groups with respect to the other cytokines and molecules that were tested. these findings suggested that thrombotic microangiopathy might be predicted at an early stage after bone marrow transplantation by detecting an increase of interleukin-12 at the time of leukocyte recovery. the possibility that thrombotic microangiopathy is related to inflammation or autoimmunity was also suggested.

Quantitative expression of erythropoietin receptor (EPO‐R) on acute leukaemia cells: relationships between the amount of EPO‐R and CD phenotypes, in vitro proliferative response, the amount of other cytokine receptors and clinical prognosis

Expression of erythropoietin (EPO) receptor (EPO‐R) was analysed in leukaemia cells from 150 patients with acute myeloid leukaemia (AML) or acute lymphoblastic leukaemia (ALL). EPO‐R was expressed in 81 (60%) out of 136 AML, and in vitro treatment with EPO led to proliferation of leukaemia cells in 13 (16%) out of 81 AML examined. EPO‐R expression and in vitro response to EPO were observed in all subtypes of AML according to the French–American–British (FAB) classification. All eight patients with FAB‐M6 expressed EPO‐R, and one out of four showed an in vitro response to EPO. Although there was no significant correlation (r = 0.2522) between the amount of EPO‐R and the in vitro response to EPO, all of the AML patients who showed in vitro response expressed EPO‐R. Stem cell factor significantly enhanced both EPO‐R expression and in vitro response to EPO. Interleukin‐3 tended to increase in vitro response to EPO. CD phenotypes, the amount of granulocyte colony‐stimulating factor (G‐CSF) receptors and the amount of TPO receptors had no significant relationship with the amount of EPO‐R. Patients with both EPO‐R expression and in vitro response to EPO had shorter duration of complete remission than those without EPO‐R (P = 0.0053). EPO‐R was expressed in four (29%) out of 14 ALL, and none out of five ALL showed in vitro response to EPO.